Nurs614 Exam 3 Liver Disease

Front 1

What is the largest organ in the body

Back 1

Liver

Front 2

How much does the liver weigh?

Back 2

~ 1500 gms (≈3.3lbs)

Front 3

Where is the liver located?

Back 3

Located under the right diaphragm

Front 4

True/false?
Significant hepatic dysfunction following anesthesia and surgery is not uncommon

Back 4

False
Most liver problems from anesthesia are transient as it is a forgiving organ & can take a lot of abuse

Front 5

How are the cells of the liver lobule arranged?

Back 5

Lobule consists of liver cells arranged in a radial pattern around a central vein

Front 6

What are the sinusoids of the liver?

Back 6

Sinusoids are endothelial lined spaces located between the liver cells.

Front 7

True/false?
Sinusoids are partly lined with Kupffer cells

Back 7

True

Front 8

What are Kupffer cells?

Back 8

Specialized macrophages located in the liver that form part of the reticuloendothelial system (aka: mononuclear phagocyte system)

Front 9

Portal tracts surround each lobule. What are these tracts composed of?

Back 9

Hepatic arterioles that surround each arterial tract
Portal venules that surround the veins
Bile canaliculi
Lymphatics
Nerves

Front 10

Where is the Space of Disse located?

Back 10

Between the sinusoids and hepatocytes

Front 11

Where does the bile canaliculi originate and what do they form?

Back 11

Between hepatocytes and join to form bile ducts

Front 12

Where does the drainage come from that forms the hepatic veins (which eventually empty into the inferior vena cava).

Back 12

Venous drainage from the central veins of hepatic lobules

Front 13

What is the oxygenation status of cells closest to the portal tract & those closest to the central veins?

Back 13

Cells closest to the portal tract are well oxygenated and those closest to central veins are less oxygenated

Front 14

What does the Space of Disse contain?

Back 14

It contains the blood plasma. Microvilli of hepatocytes extend into this space, allowing proteins and other plasma components from the sinusoids to be taken up by the hepatocytes.

Front 15

The Space of Disse may be obliterated in liver disease. What does this lead to?

Back 15

Decreased uptake by hepatocytes of nutrients and wastes (like bilirubin, for example).

Front 16

What % of the CO perfuses the liver?

Back 16

Perfused by 25-30% of CO

Front 17

Hepatice artery gets ____% total blood supply and supplies _____% of oxygen

Back 17

Hepatic artery is autoregulated, gets 25% total blood supply and supplies 50% O2

Front 18

The portal vein is a ____(high/low)pressure system that gets ___ % of total blood and supplies____ % of oxygen

Back 18

Portal vein is a low pressure system that gets 75% total blood supply & supply 50% O2

Front 19

What is the result of hepatic intrinsic regulation ?

Back 19

Hepatic artery autoregulation;
Some Metabolic control;
Some Hepatic arterial buffer response;
Relaxation/contraction to control pressure.

Front 20

What does hepatic extrinsic regulation result in?

Back 20

Neural control & influence on hormonal factors

Front 21

The liver has reservoir functions. How expandable is the liver?

Back 21

It can double in size.

Front 22

What effect can APRV ventilation potentially have on the liver?

Back 22

It can cause a back flow of blood into liver

Front 23

What are the metabolic functions of the liver?

Back 23

Carbohydrate metabolism
Fat metabolism
Protein metabolism
Also plays a significant role in hormone, vitamin, and mineral metabolism.

Front 24

One of the liver's major function is drug metabolism, what are these reactions called?

Back 24

Phase I reactions
Phase II reactions

Front 25

What is the enzyme system involved in drug metabolism in the liver?

Back 25

The Cytochrome P-450 system

Front 26

When there is a problem with the liver and drug metabolism, what is most likely the problem?

Back 26

Most problems with liver comes from blood flow problems. Drug metabolism is dependent on hepatic blood flow.

Front 27

The liver is the major site of degradation of?

Back 27

Insulin, steroid hormones, glucagon, and antidiuretic hormone

Front 28

Hepatocytes are the principle storage sites for?

Back 28

Vitamins A, B12, D, E, and K.
(Vit K is the most important to the anesthesia provider b/c of clotting).

Front 29

Bile is important in fat absorption. Name one NDMR that is dependent on this?

Back 29

Rocuronium

Front 30

The biliary system is important in the excretion of?

Back 30

Bilirubin, cholesterol & many drugs

Front 31

Hepatocytes continuously secrete?

Back 31

Bile salts, cholesterol, phospholipids, conjugated bilirubin, and other substances (into bile canaliculi).

Front 32

How is the common bile duct formed?

Back 32

Hepatic ducts combine to form right and left hepatic ducts which become the common bile duct

Front 33

Biliary flow into duodenum is controlled by?

Back 33

Sphincter of Oddi

Front 34

What is the function of the gallbladder?

Back 34

It serves as reservoir for bile. (Biliary fluid concentrated in the gallbladder between meals).

Front 35

What do bile acids do?

Back 35

They are essential for emulsifying the insoluble components of bile and facilitating the intestinal absorption of lipids

Front 36

The major route of cholesterol elimination is ?

Back 36

Bile acids represent the major route of cholesterol elimination

Front 37

What is the result of defects in the formation or secretion of bile salts?

Back 37

Interference with the absorption of fats and fat-soluble vitamins

Front 38

What is the primary end product of hemoglobin metabolism?

Back 38

Bilirubin

Front 39

Following metabolism of hemoglobin and eventual conversion to bilirubin, what happens next to the bilirubin?

Back 39

Bilirubin is then released into blood where it readily binds albumin.

Front 40

Binding to intracellular proteins traps bilirubin in the ______ where it is ______ and actively excreted into the bile caniculi and eventually into the _____ ________.

Back 40

Binding to intracellular proteins traps bilirubin inside hepatocytes where it is conjugated and actively excreted into bile canaliculi and eventually into the small intestine.

Front 41

What happens to conjugated bilirubin after it is excreted in the intestines?

Back 41

In the intestines it is converted to urobilinogen by bacterial enzymes & most is excreted through feces.
Small amounts are excreted via the urine or reexcreted in the bile.

Front 42

The most commonly performed hepatic laboratory tests are?

Back 42

ALT & AST
(They are neither sensitive nor very specific).

Front 43

What info does ALT & AST provide?

Back 43

ALT & AST, like many liver tests reflects hepatocellular integrity rather than hepatic function

Front 44

True/false?
Cirrhosis may be present with few or no laboratory abnormalities.

Back 44

True.
Because of the liver's large functional reserves.

Front 45

Liver abnormalities can often be divided into?

Back 45

Either parenchymal disorders or obstructive disorders

Front 46

Normal total bilirubin concentration is?

Back 46

< 1.5 mg/dL

Front 47

What does total bilirubin tell us?

Back 47

It reflects the balance between production and excretion of bilirubin

Front 48

At what level total bilirubin does the pt become jaundiced?

Back 48

Jaundice is usually clinically obvious when total bilirubin exceeds 3 mg/dL

Front 49

Predominantly conjugated hyperbilirubinemia is associated with?

Back 49

Urinary urobilinogen

Front 50

Predominantly unconjugated hyperbilirubinemia may be seen with?

Back 50

Hemolysis or with congenital or acquired defects in bilirubin conjugation

Front 51

Normal whole blood ammonia levels are?

Back 51

80-110 mg/dL

Front 52

Significant elevations of whole blood ammonia levels usually reflect?

Back 52

Disruption of hepatic urea synthesis.
Marked elevations usually reflect severe hepatocellular damage.

Front 53

How is an increase blood ammonia level clinically manifested?

Back 53

It results in decreased LOC -confusion.
This must be tx'd before anesthesia is given.

Front 54

Normal PT is?

Back 54

11-14 seconds

Front 55

PT measures

Back 55

Activity of fibrinogen, prothrombin, and factors V, VII, and X

Front 56

What do we use PT to assess?

Back 56

It is useful in evaluating hepatic function in acute or chronic liver disease.

Front 57

WHAT EFFECTS DOES ANESTHESIA HAVE ON HEPATIC BLOOD FLOW?

Back 57

BF usually decreases during Regional and GA.
All VAs reduce portal hepatic blood flow in proportion to decreases in MAP and CO.

Front 58

What effect does controlled positive pressure ventilation with high mean airway pressures (high PEEP and APRV ventilation) have on hepatic BF?

Back 58

Cause congestion of blood in the hepatic vessels

Front 59

Surgical procedures near the liver (like exlap)can reduce hepatic blood flow up to?

Back 59

60% (eg exlap).
Because of the clamps and retractors like the balfor that are used. Pushing on the liver reduces the reservoir.

Front 60

Endocrine response secondary to fasting and surgical trauma is generally observed. This results in?

Back 60

The release of glycogen by the liver

Front 61

What effects does regional anesthesia, deep general anesthesia, or pharmacologic blockade of the SNS have on the stress response?

Back 61

The stress response may be partially blunted by them

Front 62

What potential effect does opioids have on biliary pressure?

Back 62

All opioids can potentially cause spasm of the sphincter of Oddi and increase biliary pressure

Front 63

What possible effects does IV opioids have on cholangiograms?

Back 63

IV opioid administration can result in false-positive cholangiograms

Front 64

What is used to treat the biliary colic induced by IV opioid administration?

Back 64

Glucagon

Front 65

Mild postoperative liver dysfunction in healthy persons is not uncommon. Why?

Back 65

Because of decreased CO & BF.

Front 66

True/false?
Halothane associated hepatitis is a straightforward & direct diagnosis?

Back 66

False
Halothane associated hepatitis is a diagnosis of exclusion

Front 67

How is the range of severity of hepatitis manifested?

Back 67

Severity of syndrome can vary from asymptomatic elevation of serum transaminases to fulminant hepatic necrosis

Front 68

True/false?
Hepatitis due to enflurane or isoflurane is not very rare

Back 68

False
(And Desflurane and sevoflurane related hepatitis have not been described)

Front 69

What are the risk factors of halothane hepatitis?

Back 69

Middle age, obesity, female sex, and repeat exposure

Front 70

True/false?
Prevalence of liver disease is increasing

Back 70

False

Front 71

Cirrhosis is the major cause of death of which demographic?

Back 71

Men in their fourth and fifth decades of life

Front 72

Ten percent of patients with liver disease undergo operative procedures during what what period of the course of their illness?

Back 72

During the final two years of life

Front 73

The end stage hepatitis pt is hard to give anesthesia to. Why?

Back 73

B/c of poor blood flow

Front 74

True/false?
Clinical manifestations of hepatic dysfunction usually appears early

Back 74

Clinical manifestations of hepatic dysfunction are often absent until extensive damage has occurred

Front 75

How does anesthetics & surgery affect those pts with marginal or little reserve hepatic reserve?

Back 75

Effects from anesthetics and surgery can precipitate further hepatic decompensation in these pts.

Front 76

Acute hepatitis is usually the result of?

Back 76

Viral infection, drug reaction, or exposure to hepatotoxin

Front 77

Acute hepatitis represents?

Back 77

Acute hepatocellular injury with variable amounts of cell necrosis

Front 78

Mild inflammatory reactions may present as asymptomatic elevations in serum transaminases. How is this reflected in the AST/ALT?

Back 78

There may be only be a mild elevation in AST/ALT

Front 79

In acute hepatitis, massive necrosis presents as?

Back 79

Acute fulminant hepatic failure

Front 80

Viral hepatitis is most commonly due to?

Back 80

Hepatitis A, B, or C viruses

Front 81

Hepatitis types A and E are transmitted by what route?

Back 81

Oral-fecal route

Front 82

How are Hepatitis B and C are primarily transmitted?

Back 82

Percutaneously and by contact with body fluids.

Front 83

True/false?
Epstein-Barr, HSV, CMV, and coxsackieviruses may also cause hepatitis

Back 83

True

Front 84

How is Hepatitis D transmitted?

Back 84

Percutaneously and by contact with body fluids.
Its transmission requires the presence of hepatitis B.

Front 85

Drug-induced hepatitis can result from?

Back 85

Direct dose-dependent toxicity of a drug
or an idiosyncratic drug reaction

Front 86

True/false?
The course of drug-induced hepatitis presents very differently from viral hepatitis

Back 86

False
The course of drug-induced hepatitis resembles viral hepatitis

Front 87

Drug-induced hepatitis may be associated with?

Back 87

Alcohol consumption
Acetaminophen ingestion
Ingestion of potent hepatotoxins
Volatile anesthetics

Front 88

Chronic hepatitis is defined as?

Back 88

Persistent hepatic inflammation for longer than six months, as evidenced by elevated serum aminotransferases

Front 89

Patients usually classified as having a distinct syndrome based on liver biopsy usually have one of these 3 types of hepatitis:

Back 89

Chronic persistent hepatitis
Chronic lobular hepatitis
Chronic active hepatitis

Front 90

As anesthetic consideration for acute hepatitis, how should elective surgeries be handled?

Back 90

They should be postponed until acute episode has resolved

Front 91

Elective surgeries should be postponed until acute episode has resolved. Why?

Back 91

Patients with hepatitis are at risk for deterioration of hepatic function and development of complications from hepatic failure.
Liver problems can predispose pt to complications.

Front 92

What is the VA of choice in pts with hepatitis?

Back 92

Isoflurane

Front 93

The most common cause of cirrhosis is related to?

Back 93

Alcohol consumption
(Laennec’s cirrhosis)

Front 94

Besides ETOH, what are other causes of cirrhosis?

Back 94

Chronic active hepatitis
Chronic biliary inflammation or obstruction
Chronic right-sided CHF
Hemochromatosis
Wilson’s disease
Antitrypsin deficiency

Front 95

Chronic r/sided CHF causes cirrhosis. Why?

Back 95

B/c of the back flow of blood which can lead to portal HTN.

Front 96

Hepatocyte necrosis in cirrhosis is followed by?

Back 96

Fibrosis and nodular regeneration.

Front 97

In cirrhosis, portal venous flow obstruction eventually lead to?

Back 97

Portal hypertension

Front 98

In cirrhosis, how does clinical manifestations correlate to severity of the disease?

Back 98

Signs and symptoms do not correlate with disease severity.
Manifestations are initially absent.
Jaundice and ascites eventually develop in most patients.

Front 99

Cirrhosis is generally associated with development of three major complications. What are they?

Back 99

Variceal hemorrhage from portal hypertension;
Intractable fluid retention;
Hepatic encephalopathy or coma.

Front 100

Which vasoactive drug should be avoided in pts with cirrhosis r/t variceal hemorrhage from portal HTN?

Back 100

NGTs, as it can cause extensive bleeding. If varice ruptured, tamponade with blakemore tube.

Front 101

Pts with cirrhosis may present with a spontaneous type of bacterial infection and a type of cancer. What are these?

Back 101

Bacterial peritonitis, and hepatocellular carcinoma.

Front 102

Gastrointestinal manifestations of cirrhosis?

Back 102

Portal hypertension:
Ascites
Esophageal varices
Hemorrhoids
 Gastrointestinal bleeding

Front 103

Circulatory manifestations of cirrhosis?

Back 103

Hyperdynamic state;
Systemic arteriovenous shunts.

Front 104

Pulmonary manifestations of cirrhosis?

Back 104

Increased intrapulmonary shunting
Decreased functional residual capacity
Pleural effusions
Restrictive ventilatory defect

Front 105

Renal manifestations of cirrhosis?

Back 105

Increased proximal/distal reabsorption of sodium
Impaired free water clearance:
Decreased renal perfusion
Hepatorenal syndrome (renal failure b/c of liver failure)

Front 106

Hematologic manifestations of cirrhosis?

Back 106

Anemia
Coagulopathy:
Hypersplenism (large spleen from blood back up)
Thrombocytopenia
Leukopenia

Front 107

Infectious manifestations of cirrhosis?

Back 107

Spontaneous bacterial peritonitis

Front 108

Metabolic manifestations of cirrhosis?

Back 108

Hyponatremia
Hypokalemia
Hypomagnesemia
Hypoalbuminemia
Hypoglycemia

Front 109

Neurologic manifestations of cirrhosis?

Back 109

Encephalopathy

Front 110

Intraoperative considerations r/t cirrhosis:
Patients with post-necrotic cirrhosis due to hepatitis B or C who are carriers of the virus may be infectious.
What should the anesthesia provider do?

Back 110

Wear eye protection & face mask and avoid needle sticks!!!

Front 111

Intraoperative considerations r/t cirrhosis:
What adjustments need to be made in NMBAs and why?

Back 111

Use smaller than normal doses of those NMBAs that are dependent on hepatic elimination.

Front 112

Intraoperative considerations r/t cirrhosis:
How should drugs that are hepatically eliminated be dosed?

Back 112

They should be titrate to effect since pts are very sensitive & may have hyper-response


Front 113

How does cirrhosis affect succinycholine?

Back 113

There may be a prolonged duration of action

Front 114

What is the NDMBA of choice in the cirrhotic pt?

Back 114

Cisatracurium

Front 115

How does cirrhosis affect opioids?

Back 115

Half-lives of opioids are often significantly prolonged

Front 116

If the pt has abdominal distension d/t massive ascites, what should the anesthesia provider do?

Back 116

This must be noted in the plan of care.
A decision must be made regarding drainage & how provider must be cognizant of how drnge will affect the fluid shift.

Front 117

In the cirrhotic pt, close respiratory and cardiovascular monitoring is necessary when undergoing abdominal procedures. What should supplement use of the pulse ox?

Back 117

Pulse oximetry must be supplemented with ABG analysis.
(Also, use of PEEP & intra-arterial, CVP & PAC monitoring may be indicated for most patients).

Front 118

In the cirrhotic pt, what is the intraop consideration for N2O

Back 118

N2O may not be tolerated

Front 119

In the cirrhotic pt, if an Aline is to be placed, what needs to be checked first?

Back 119

Coags

Front 120

In the cirrhotic pt, intraoperative preservation of intravascular volume and urinary output takes priority. What strategies can the a/provider employ to ensure adequate fluid status?

Back 120

Urinary output must be monitored closely;
Watch fluids, keep intravascular volumes normal. If intravascular volumes normal (per CVP) and BP still low, may need pressors. Use a direct acting agent that works on arterial side.

Front 121

In the intraop cirrhotic pt with normal intravascular volumes (per CVP) but low BP who needs a pressor, why does a pressor that constricts venous vessels contraindicated?

Back 121

Squeezing the venous side will make the portal HTN worse

Front 122

In the intraop cirrhotic pt who needs fluid, why may predominant use of colloids be preferable?

Back 122

It avoids sodium overload and increase oncotic pressure

Front 123

In the intraop cirrhotic pt who is getting colloids, why does the a/provider have to be careful with its use?

Back 123

B/c these pts have leaky vessels & colloids could end up in abd cavity

Front 124

HEPATOBILIARY DISEASE
is often characterized by?

Back 124

Cholestasis

Front 125

What is the most common cause of extrahepatic obstruction of the biliary tract?

Back 125

HEPATOBILIARY DISEASE

Front 126

How do pts with hepatobiliary disease present?

Back 126

Patients present with progressive jaundice, dark urine with pale stools, and/or pruritis

Front 127

Intrahepatic cholestasis most commonly results from?

Back 127

Viral hepatitis or an idiosyncratic drug reaction

Front 128

Treatment for extrahepatic/intrahepatic cholestasis is?

Back 128

Surgical removal of the gall bladder or placement of a stent to promote drainage

Front 129

Pts with HEPATOBILIARY DISEASE
usually present to the OR for?

Back 129

Cholecystectomy, relief of extrahepatic biliary obstruction, or both

Front 130

Common hepatic surgical procedures include?

Back 130

Repair of lacerations
Drainage of abscesses
Resections of tumors

Front 131

Intraop considerations for hepatic surgery?

Back 131

Consider potential large blood loss (can be liters)
Hemodynamic invasive monitoring indicated - will have an Aline, CVC, maybe CVP

Front 132

POSTOPERATIVE JAUNDICE r/t complications of anesthesia for liver disease may be caused by?

Back 132

Prehepatic (increased bilirubin production);
Hepatic (hepatocellular dysfunction);
Possibly b/c of liver resection (decrease blood flow);
Posthepatic biliary obstruction (possibly spasm of Oddi, decrease blood flow, etc.)