Term
| What are the 7 functions the liver is involved in? |
|
Definition
1. Storage and filtration of blood
2. Metabolic functions
3. Secretion of bile
4. Storage of vitamins
5. blood coagulation
6. storage of iron
7. immunization and detoxification/excretion of drugs |
|
|
Term
| The liver receives what percentage of cardiac output? |
|
Definition
|
|
Term
| The hepatic artery delivers ___% of total blood flow but ____% of the hepatic oxygen supply. |
|
Definition
|
|
Term
| The portal vein delivers ___% of total blood flow but ____% of the hepatic oxygen supply. |
|
Definition
|
|
Term
| The portal vein is formed by the confluence of which veins? |
|
Definition
| The splenic and superior mesenteric veins. |
|
|
Term
| The pressure through the hepatic portal system is ____ |
|
Definition
|
|
Term
| A portal triad consists of what three components? |
|
Definition
1) a portal vein
2) a hepatic artery
3) a bile duct |
|
|
Term
|
Definition
- lies closest to the oxygen rich blood vessel
-contains many mitochondria
-has the largest amount of enzymes used in the Kreb's cycle |
|
|
Term
|
Definition
-functions in a primarily anaerobic environment
-its involved in glycolysis and lipogenesis
-primary site for drug detoxification/biotransformation of drugs and toxins
-most vulnerable to hypoxia
-most vulnerable to drug toxicity (acetaminophen) |
|
|
Term
| Blood glucose within the liver increases due to activation of what receptor? |
|
Definition
|
|
Term
| What are the effects of the sympathetic nervous system in the liver? |
|
Definition
| It reduces blood flow through the liver and decreases the metabolism of the liver. |
|
|
Term
| What are the effects of the parasympathetic nervous system in the liver? |
|
Definition
| It increases glucose uptake in the liver and produces glycogen synthesis and storage. |
|
|
Term
| What receptors are located in the hepatic artery system? |
|
Definition
alpha 1
beta 2
cholinergic receptors
D1 receptors |
|
|
Term
| What receptors are located in the portal vein system? |
|
Definition
|
|
Term
| Anesthetics that impair the ____ _____ ____ impair the blood reservoir function of the liver. |
|
Definition
| Sympathetic Nervous System |
|
|
Term
| _____% of total blood volume is coursin through the liver. |
|
Definition
|
|
Term
| With intense _______ ______ (pain, stress loss of blood volume), ____% of the liver's reserve can be autotransfused within seconds. His is approximately ____ml of blood |
|
Definition
| sympathetic discharge, 80%, 500ml |
|
|
Term
| The ____ ____ ____ plays a crucial role in the autotransfusion of blood from the liver to the systemic circulation. |
|
Definition
|
|
Term
| The liver is the site for producing clotting factors, except for which one that is produced by hepatocytes and endothelial cells? |
|
Definition
| Von Willebrand (VIII vWF) |
|
|
Term
| What are the vitamin K dependent clotting factors made in the liver? |
|
Definition
|
|
Term
| The liver regulates platelets through the production of ______ |
|
Definition
|
|
Term
| What anticoagulant factors does the liver produce? |
|
Definition
Antithrombin III
Protein C
Protein S
Fibrinolytic Factors such as plasmin |
|
|
Term
| The liver is the primary site of _____ catabolism |
|
Definition
|
|
Term
| What is the end product of heme degradation? |
|
Definition
|
|
Term
| Heme degradation occurs via the _____ ______ system |
|
Definition
| phagocytic reticuloendothelial system |
|
|
Term
| Bilirubin production and conjugatoin: Heme is separated from hemoglobin and then oxidized into _____, this substance is converted to _______ bilirubin which goes into the blood and binds to ______, this substance takes it to the liver and ______ it. and it is released into the ____, and the gut converts it to ______. |
|
Definition
| biliverdin, unconjugated, albumin, conjugates, bile, urobilirubin |
|
|
Term
| Urobilirubin is excreted where? |
|
Definition
| Mostly in the stool, some in the urine |
|
|
Term
| Why is it important for free hemoglobin to bind to hepatoglobin? |
|
Definition
| This protein returns free HGB to the liver to be processed and to conserve iron. |
|
|
Term
| physiologic functions of the liver |
|
Definition
1) hormone synthesis
2) hormone catabolism and biotransformation
3) erythrocyte breakdown
4) bilirubin excretion |
|
|
Term
|
Definition
-abdominal pain
-cutaneous rash
-peripheral neuropathy |
|
|
Term
| Porphyria is classified according to what 3 characteristics? |
|
Definition
1) site of abnormal porphyrin production (hepatic vs erythropoietic)
2) acute vs nonacute
3) measured enzyme deficiency (lab result) |
|
|
Term
| Porphyria is a group of inherited or acquired _____ ____ of _____ biosynthesis. |
|
Definition
|
|
Term
| In porphyria, what compound accumulates can what can it do in the skin? |
|
Definition
| Porphyrins, they can cause skin breakouts |
|
|
Term
| What drug accounts for the majority of drug-precipitated porphyria attacks? |
|
Definition
|
|
Term
| Should you do regional in someone with porphyria? |
|
Definition
| Probably not, especially if they have neuropathy |
|
|
Term
| Is Valium a trigger for porphyria? how about versed or lorazepam? |
|
Definition
| Yes, valium is a trigger, but versed and lorazepam are okeedokee |
|
|
Term
| What is the induction drug of choice in porphyria? |
|
Definition
| Propofol (ketamine and etomidate have been implicated as triggers in animal studies) |
|
|
Term
| What kind of muscle relaxants should be used in porphyria? |
|
Definition
Non-steroidals (like cisatracurium)
b/c steroids are thought to potentiate attacks. |
|
|
Term
| What antihypertensives are ok to use in porphyria and what are not? |
|
Definition
Ok to use beta blockers, especially propranolol.
Do not use hydralazine |
|
|
Term
| ____% of patients in porphyria crisis will have a seizure |
|
Definition
|
|
Term
| What can you use to treat a seizure in someone with porphyria? |
|
Definition
Versed and lorazepam
No diazepam!! |
|
|
Term
| Since catabolic states worsen porphyrin production, you should use what IVF? |
|
Definition
|
|
Term
| Porphyria pts are prone to what electrolyte abnormality? |
|
Definition
|
|
Term
| 4 metabolic functions of the liver |
|
Definition
1) carbohydrate metabolism
2) amino acid metabolism
3) lipid metabolism
4) synthesis of proteins (albumin |
|
|
Term
| What proteins are not produced by the liver? |
|
Definition
| Most are produced by the liver except for immunoglobulins |
|
|
Term
| Half life of albumin is... |
|
Definition
|
|
Term
| T/F: Albumin levels are a good indicator of acute liver failure. |
|
Definition
False: albumin is not a good indicator of acute liver failure due to its long half-life
"albumin is a good indicator for chronic liver failure" |
|
|
Term
| What is the name of the phagocytes within the reticuloendothelial system in the liver? |
|
Definition
|
|
Term
| What is the name of the phagocytes within the reticuloendothelial system in the skin? |
|
Definition
|
|
Term
| Drug metabolism is primarily a _____ event |
|
Definition
|
|
Term
| Most phase 1 reactions involve the _____ ___ system |
|
Definition
|
|
Term
| Phase II reactions _____ the ______ ______ of the drug byproducts |
|
Definition
| enhance, water solubility |
|
|
Term
| Phase II reactions involve what processes? |
|
Definition
| acetylation, glycination, glucuronidation, sulfonication |
|
|
Term
| In a neonate, which drug biotransformation reactions are not fully functional, and which are fully functional? |
|
Definition
| Conjugation reactions are not fully functional (except sulfonication), and the cytochrome P450 system is functional |
|
|
Term
| Why do neonates get jaundice? |
|
Definition
| Because they cannot conjugate bilirubin through glucuronidation |
|
|
Term
| All biotransformation reactions are mature by age ___ |
|
Definition
|
|
Term
| Why is the neonate more susceptible to adverse effects of morphine? |
|
Definition
| Because hepatic conjugation of morphine is reduced and renal clearance of morphine metabolites is reduced. So it will build up and they will stop breathing. Watch out! |
|
|
Term
| ____ __ reactions are more susceptible to inhibition by advanced age or hepatic diseases. |
|
Definition
|
|
Term
| Can you use one lab test to assess liver function? |
|
Definition
| No. No one test can determine overall hepatic function. |
|
|
Term
| Will you see lab changes with cirrhosis of the liver? |
|
Definition
| Maybe not because the liver has such a reserve that little to no lab value change may be present. |
|
|
Term
| What are two sensitive indicators of severe hepatic dysfunction? |
|
Definition
|
|
Term
| In obstructive jaundice, the production of what vitamin K dependent factor is reduced? And what lab value will change with it? |
|
Definition
| Factor VII is reduced, and PT will be prolonged. |
|
|
Term
| ____ is the most commonly used radiographic technique to assess the liver, followed by ___ or ____ |
|
Definition
|
|
Term
| What is a potential problem we would encounter if called to sedate a pt undergoing a percutaneous transhepatic cholangiography? |
|
Definition
| An allergic reaction from the dye, particularly if pts are allergic to iodine and shellfish. |
|
|
Term
| The sphincter of oddi provides an opening to what structure? |
|
Definition
|
|
Term
| In what procedure does the surgeonneed to pass a wire through the ampulla of Vater? And what drug can you give to help relax the sphincter of Oddi to promote insertion of the wire? |
|
Definition
| Endoscopic retrograde cholangiopancreatography, you can give glucagon |
|
|
Term
| What are the 2 classifications of liver disease? |
|
Definition
1) Parenchymal (functional liver cells)
2) Cholestatic (gallbladder) |
|
|
Term
| The most common causes of acute viral hepatitis are... |
|
Definition
Hepatitis A (oral-fecal route)
Hepatitis B (blood and body fluid)
Hepatitis C (blood and body fluid) |
|
|
Term
| What acute viral hepatitis most commonly progresses to a chronic condition? |
|
Definition
|
|
Term
| The most common cause of drug-induced hepatitis? |
|
Definition
|
|
Term
| What factors reduce hepatic blood flow in anesthesia? |
|
Definition
-Volatile anesthetics decrease it.
-Halothane reduces it the most and isoflurane reduces it the least.
-Regional and general blocks reduce liver blood flow because the SNS is blocked (this may not be 100% accurate, it may be the opposite)
-Upper abdominal surgery
-Regional SAB at T-4
-Hypocarbia |
|
|
Term
| What factors increase hepatic blood flow in anesthesia? |
|
Definition
|
|
Term
| Upper abdominal surgery can reduce liver flow by as much as ___% |
|
Definition
|
|
Term
| Regional SAB of T-4 reduces hepatic blood flow by ____% |
|
Definition
|
|
Term
| The incidence of halothane hepatits increases with a _____ _____ within _____ ____ |
|
Definition
| previous exposure, 28 day |
|
|
Term
| What group is most at risk for halothane hepatitis? |
|
Definition
|
|
Term
| Chronic hepatitis definition |
|
Definition
| Any liver disorder which produces hepatic inflammation and necrosis for at least 6 months |
|
|
Term
| What is the most common cause of chronic liver disease in the US? |
|
Definition
| non-alcoholic fatty liver disease |
|
|
Term
| Non-alcoholic fatty liver disease, is more prevalent in men or women? And what decade of life does it appear in? |
|
Definition
| More common in women, and shows up in the 5th-6th decades of life. |
|
|
Term
| Two major risk factors for Non-Alcoholic Fatty Liver Disease? |
|
Definition
1) Type II diabetes
2) Obesity |
|
|
Term
| What are the 3 types of liver damage that follow heavy alcohol consumption? |
|
Definition
1) Steatosis
2) Alcohol Hepatitis
3) Cirrhosis |
|
|
Term
|
Definition
|
|
Term
| Treatment for alcohol hepatitis which presents as jaundice? |
|
Definition
Abstinence
High-protein diet
Bedrest
Corticosteroids |
|
|
Term
| Elective surgery should be delayed until acute hepatitis has _____ |
|
Definition
| Resolved (normal lab tests) |
|
|
Term
| Acute hepatitis carries a ____% increase in morbidity and mortality |
|
Definition
|
|
Term
| Surgery on someone in alcohol withdrawal has a ___% ____!! |
|
Definition
|
|
Term
| What electrolyte abnormalities may you see in acute and chronic hepatits? |
|
Definition
Hypokalemia
Metabolic acidosis
Hypomagnesemia |
|
|
Term
| Hypomagnesemia predisposes chronic alcoholics to what? |
|
Definition
|
|
Term
| WHat is the best indicator of hepatic dysfunction? |
|
Definition
|
|
Term
| PT ___ seconds or an INR ___ after vitamin K is given, = _____ _____ |
|
Definition
| >3 seconds, >1.5, hepatic dysfunction |
|
|
Term
| Should you pretreat a pt with acute/chronic hepatitis with benzos? |
|
Definition
| No, due to encephalopathy |
|
|
Term
| Alcohol is a _____ depressant |
|
Definition
|
|
Term
| Are opioids prolonged in acute/chronic hepatitis? |
|
Definition
|
|
Term
| Is succs prolonged in acute/chronic hepatitis? |
|
Definition
|
|
Term
| What about NDMRS in acute/chronic hepatitis? |
|
Definition
| Avoid if they use the liver for metabolism |
|
|
Term
| What gas is best in acute/chronic hepatitis? |
|
Definition
| Isoflurane because it reduces liver blood flow the least. |
|
|
Term
| ____ + ____ produce an additive myocardial depressant effect in acute/chronic hepatitis |
|
Definition
| alcohol, volatile anesthetic |
|
|
Term
| What are the most common etiology for liver cirrhosis in the US? |
|
Definition
| Chronic Hepatitis C & Alcoholism |
|
|
Term
| Symptoms of liver cirrhosis |
|
Definition
Anorexia
Weakness
N/V
Abdominal Pain |
|
|
Term
|
Definition
Hepatosplenomegally
ascites
jaundice
spider nevi
metabolic encephalopathy |
|
|
Term
| T/F: liver cirrhosis can impact every organ in the body |
|
Definition
|
|
Term
| What is the hallmark of end stage cirrhosis? |
|
Definition
|
|
Term
| Two contributing factors of portal hypertension |
|
Definition
1) Increased vascular resistance
2) Increased portal blood flow |
|
|
Term
| What changes occur in the liver to cause increased vascular resistance? |
|
Definition
-Direct blockage or damage at the sinusoid (as in cirrhosis)
-Damaged tissue is replaced by fibrous and nodular tissue that distort/compresses the portal venous system. |
|
|
Term
| Gastro-esophageal varices are present in ____ % of all cirrhotic patients. ____% will bleed. ____% of the initial bleeds are fatal |
|
Definition
|
|
Term
| Esophageal varices allow blood flow from a ____ _____ portal system to a _____ _____ alternative route (the esophageal varices). |
|
Definition
| high pressure, lower pressure |
|
|
Term
| List the 9 treatments for Esophageal Varices treatment (helpful Mnemonic on the next slide) |
|
Definition
FUC! Stop The Bleeding Now Before Expiration! (All the capitalized letters count)
1) Fluid resuscitation
2) Upper GI endoscopic banding
3) Correction of coagulopathy
4) Sandostatin
5) Transjugular intrahepatic portal systemic shunt (TIPS)
6) Blood transfunsions
7) Non-selective beta blocker
8) Balloon Tamponade
9) ETT Intubation |
|
|
Term
| Considerations for TIPS procedure (see Mnemonic on other side) |
|
Definition
SECCAM
1) Still patient (muscle relaxant)
2) Electrolytes are messed up
3) Coagulopathy- get a type and screen
4) CVP for difficult fluid management
5) Arterial Line
6) Multiple IVs (more than one IV) |
|
|
Term
|
Definition
-reduce sodium intake
-water restriction
-diuretics |
|
|
Term
| What is the most common major complication of cirrhosis? |
|
Definition
|
|
Term
| Paracentesis of ascites fluid is good because it can improve _____ _____ (preload), but afterward patients will need ______ ____ _____ with _____. |
|
Definition
| cardiac output, intravascular fluid expansion, albumin |
|
|
Term
| What is a complication of ascites? |
|
Definition
|
|
Term
| ___% of people with cirrhosis develop ascites within ___ years of diagnosis. ___% of patients with ascites die within __ years. |
|
Definition
| 50%, 10 years, 50%, 3 years |
|
|
Term
| In paracentesis of ascites, you should not exceed ______ for a daily weight loss of ______ kg. |
|
Definition
|
|
Term
| 1 liter of ascites fluid contains how many grams of albumin? |
|
Definition
|
|
Term
| Each liter of ascites fluid that is removed needs to be replaced by how much albumin (how many mls of what percentage?)? |
|
Definition
|
|
Term
| What are the 3 main renal function problems that occur in cirrhosis? |
|
Definition
1) Reduced Na excretion
2) Hepatorenal syndrome
3) Acute renal failure and tubular necrosis |
|
|
Term
|
Definition
-is a pre-renal failure
-intense vasoconstriction of the renal circulation
-Low GFR
-Preserved renal function |
|
|
Term
| The extreme vasodilation of the splanchnic areteries in renal failure is driven by what 3 substances? |
|
Definition
-prostacycline
-nitric oxide
-glucagon |
|
|
Term
| Acute renal failure in pts with cirrhosis often occurs after what precipitating events? |
|
Definition
-Sepsis
-Hypotensive episodes |
|
|
Term
| Acute Tubular Necrosis in cirrhosis, what are two pathologies? |
|
Definition
1) Moderate hemorrhage can produce severe hypotension causing ATN
2) In a jaundiced pt, the bilirubin is toxic to the renal tubules causing ATN |
|
|
Term
| Encephalopathy neuro symptoms |
|
Definition
-confusion
-neuromotor abnormalities
-coma |
|
|
Term
| What toxins build up in encephalopathy? |
|
Definition
| Ammonia, phenols, and increased GABA |
|
|
Term
| What inhibitory neurotransmitter is increased in encephalopathy? |
|
Definition
|
|
Term
| Is it ok to give benzos preop for someone with encephalopathy? |
|
Definition
| No WAAAYYY!! they have enhanced uptake of benzos, possibly due to break down of the BBB. |
|
|
