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- Mild hepatitis: Aminotransferase Concentrations <500IU/L
- Anemia and lymphocytosis are typically present
- Specific etiology determined by serologic testing
Drug Induced Hepatitis
- Acetaminophen Overdose: Discontinue and give N-acetylcysteine within 8 hours.
- Volatile Anesthetics: May produce mild, self-limiting post liver dysfunction due to hepatic oxygen supply. Halothane hepatitis may be due to an immune-mediated hepatotoxicity.
Differential of Postoperative Hepatic Dysfunction
- Types: Prehepatic, Intrahepatic (hepatocellular), Posthepatic (cholestatic)
- Labs: Bilirubin, aminotransferase, alkaline phosphatase
- Differential based on labs: Drugs, sepsis, increased exogenous bilirubin (blood transfusion), hematoma, Hemolysis, benign postoperative hepatic cholestasis, immune related hepatotoxicity, check preoperative records for hypotension, hypoxemia, hypoventilation, and hypovolemia
- B:Increased unconjugated
- ALT/AST: normal
- AlkPhos: normal
- Causes: hemolysis, hematoma, bilirubin overload from blood transfusion
Intrahepatic (hepatocellular dysfunction)
- B: Increased conjugated
- ALT/AST: Increased
- AlkPhos: N/slightly increased
- Causes: viral, drugs, sepsis, hypoxemia, cirrhosis
- B: Increased conjugated
- AST/ALT: N/slightly increased
- AlkPhos: Increased
- Causes: sepsis, biliary tract stones
- Commonly viral (HBV/HCV) or immune
- AST/ALT: elevated
- B: Normal w/viral and increased w/autoimmune
- Severe: decreased albumin and prolonged PT
- Immune: Increased gamma globulin, tx w/ corticosteroids and azathioprine
- HBV: age at initial infection is major determinant of chronicity
- HCV: Most common
Liver Cirrhosis: Info and Types
- Causes: alcoholism, postnecrotic (viral, autoimmune, cryptogenic), primary biliary, hemochromatosis, Wilson's Disease, alpha1 antitrypsin deficiency, nonalcoholic steatohepatitis,
- Decreased hepatic blood flow due to increased resistance through the portal vein (portal HTN). This leads to an increased proportion of hepatic blood through the hepatic artery
- A: decreased
- PT: prolonged
- AST/ALT: increased
- AlkPhos: Increased
Liver Cirrhosis: Complications
- Portal HTN: increased resistance through the portal venous system
- Gastroesophageal Varices: tracheal intubation may be needed to prevent aspiration of blood. Bleeding = 1/3 of deaths due to cirrhosis
- Ascites: Tx w/ spironolactone
- Hyperdynamic circulation: Increased CO due to peripheral and splanchnic vasodilation, increased IV fluid, decreased blood viscosity (anemia), and arteriovenous communications.
- Arterial hypoxemia: PaO2 60-70mmHg
- Hetatorenal syndrome: functional renal failure w/o intrinsic abnormality of the kidneys.
- Hypoglycemia: Inability to convert lactic acid to glucose.
- Duodenal Ulcers:
- Spontaneous bacterial peritonitis:
- Hepatic encephalopathy:
- Primary hepatocellular carcinoma:
Liver Cirrhosis: Anesthesia Preoperative
- Identify problems that can be optimized preoperatively (cardiorespiratory function, coagulation, renal function, IV fluids, electrolyte balance, malnutrition).
- Vitamin K if prolonged PT.
- Chronic alcoholism increases MAC.
- Acute alcohol intoxication: Decreased MAC requirement, increased regurgitation risk, platelet interference,
Liver Cirrhosis: Anesthesia Intraoperative
- Hepatic flow seems maintained during admin of volatiles (except halothane)
- IV anesthetics are valuable w or w/o N2O.
- Muscle relaxants: Hepatic clearance must be considered. Ascites causes a higher dose needed. Cisatracurium elimination is not affected.
- Monitoring: Maintain acceptable urine output to help decrease renal failure. Glucose infusion may be needed to prevent hypoglycemia. Avoid unnecessary esophageal instrumentation in patients with esophageal varies.
Causes: increased bilirubin production, decreased hepatic uptake of bilirubin, or decreased conjugation
Causes: decreased canalicular transport of bilirubin, acute or chronic hepatocellular dysfunction, or obstruction of the bile ducts.
- Gilbert's syndrome: Most common hereditary form. Glucoronosyl transferase enzyme mutation
- Crigler-Najjar Syndrome: Hereditary unconjugated hyperbilirubinemia.
- Dubin-Johnson: Conjugated hyperbilirubinemia
- Benign postoperative intrahepatic cholestasis: often following prolonged surgery
- Progressive familial intrahepatic cholestasis:
Acute Liver Failure: Info
- Causes: viral and drug induced (most common), toxin, ischemia, acute fatty liver of pregnancy, Reye's syndrome.
- S/S: Prolonged PT, malaise, nausea, jaundice, altered mental status, coma.
- Labs: Increased aminotransferases,, hypoglycemia, respiratory alkalosis.
Acute Liver failure: Anesthesia
- Only perform surgery to correct life-threatening problems.
- Coagulation correction: fresh frozen plasma (all factors)
- Low doses of volatiles or N2O.
- IV anesthetics may have prolonged effects
- Muscle relaxants: consider cisatracurium.
- Glucose to tx. hypoglycemia.
Liver transplantation: Anesthesia
- Induction can be affected by the presence of ascites compromising lung volumes and delaying gastric emptying
- Hypoxemia and pulmonary aspiration are significant risks.
- N2O often avoided due to bowel distension.
- Stages: Dissection, anhepatic, reperfusion/neohepatic
Liver transplant recipients: Anesthesia
Chronic immunosuppression: may cause systemic HTN, anemia, thrombocytopenia, and altered drug effects
- Info: obstruction of the cystic duct (gallstones/cholelithiasis) producing acute inflammation of the gallbladder.
- S/S: Severe pain in the mid-epigastrium radiating to the UR quadrant and may radiate to the back due to a biliary colic.
- Complications: Due to inflammation and necrosis of the gallbladder.
Acute Cholecystitis: Anesthesia for laparoscopic cholecystectomy
- Insufflation of the abdomen interferes with ventilation and decreases venous return&CO and increased MAP and SVR.
- Endotracheal intubation with a cuffed tube minimizes the risk of pulmonary aspiration
- CO2 embolism may be the cause for a CV collapse and capnography is important to recognize it.
- Cardiac dysrhythmias may occur due to hypercarbia.
- Opioids may cause spasm of the sphincter of Oddi (tx w/ naloxone or glucagon, possibly NTG).