Liver
What is the most sensitive assessment for acute liver injury, be specific, and why?
What is the most specific indicator for Biliary obstruction?
1- Serum amino transferases are the most sensitive markers for acute hepatic injury and are common in all forms. ALT is more specific than AST in hepatic injury. Note that if both are elevated, this indicates hepatitis.
2- Elevated 5 nucleotidase is specific for liver disease and some sources state that it is the most specific indicator for biliary obstruction.
Slide 15
For what patients are laparoscopic approaches to cholecystectomy contraindicated?
If they can not tolerate the physiologic implications of pneumoperitoneum. Patients who are extremely obese, or have sever lung or cardiac disease are not candidates.
Slide 40
What are the 3 approaches for Esophagectomy and the end result of these approaches?
•Laparotomy with right thoracotomy (supine to left lateral)
•Trans hiatal approach (supine, abdominal and neck incisions)
•Left thoracoabdominal approach (right lateral)
End result- a portion of the stomach is used to replace the esophagus Stomach is mobilized while maintaining the blood supply and transposed into the chest.
slide 55
True or False: Multimodal pain management for breast cancer surgery can include medications such as acetaminophen, gabapentin, and celecoxib.
True.
slide 82
How might hepatic blood flow be affected by anesthetics, mechanical ventilation, and surgical procedures?
•General /Neuraxial- decreases in MAP and cardiac output, and as a result of sympathectomy from neuraxial anesthetics. Patients with liver disease are more vulnerable to the anesthetic effects on hepatic blood flow.
•Mechanical ventilation can decrease hepatic blood flow. –impair venous return and decrease CO. hypocapnia and alkalosis cause vasoconstriction and decrease blood flow to the liver.
•Surgeries associated with decreased hepatic blood flow include intraabdominal surgeries and laparoscopic surgeries. Traction on abdominal organs, hypotension, hemorrhage and pneumoperitoneum disrupt blood flow to the liver.
Slide 14
What does an elevated bilirubin indicate?
elevated bilirubin is neither specific nor diagnostic. (However, marked elevations are present in bile duct obstruction and hepatitis. Bilirubin may be markedly elevated in many types of liver diseases, but once again, is not diagnostic.)
slide 15
Which of the following statements about gallbladder disorders is true?
A) Cholecystitis can occur due to both infection and obstruction, with obstruction often caused by external tumors or gallstones blocking the cystic duct.
B) The Murphy sign is characterized by pain that improves upon inspiration and is indicative of gallbladder disease.
C) The most specific diagnostic tool for acute cholecystitis is the CT scan, as it provides a detailed view of gallbladder anatomy.
D) Dark urine and scleral icterus are not common symptoms of acute cholecystitis, as they are more associated with liver disorders.
A) Cholecystitis can occur due to both infection and obstruction, with obstruction often caused by external tumors or gallstones blocking the cystic duct.
slide 37
A patient is scheduled for a thoracotomy due to esophageal malignancy. During the preoperative assessment, which of the following statements is accurate regarding the management and considerations for this surgical procedure?
A) A double-lumen tube (DLT) is necessary for all thoracotomy approaches, and preoperative pulmonary function tests (PFTs) are not required if the patient has a normal respiratory history.
B) Rapid sequence intubation (RSI) is not recommended, and it is essential to maintain the DLT throughout the procedure without considering tube exchanges.
C) It is important to administer heparin at a dose of 5,000 U SQ, ensure large bore IV access, and prepare for possible postoperative complications such as respiratory alterations and RLN injury.
D) Preoperative antibiotics are not required, and patients typically spend more than 2 days in the ICU following surgery.
C) It is important to administer heparin at a dose of 5,000 U SQ, ensure large bore IV access, and prepare for possible postoperative complications such as respiratory alterations and RLN injury.
slide 56
What is a key consideration when performing a sentinel node mapping procedure in breast surgery?
A) Nondepolarizing muscle relaxants can be used to facilitate the procedure without risk.
B) Intraoperative injection of blue dye into the nipple region is crucial for the procedure's success.
C) Patients should receive a high dose of Toradol to manage pain during the surgery.
D) Local anesthesia is contraindicated when performing sentinel node mapping.
B) Intraoperative injection of blue dye into the nipple region is crucial for the procedure's success.
slide 84
What is the pathology and prerenal sequence of events that lead to development of hepatorenal syndrome?
•Results from chronic liver disease, hepatic failure, portal hypertension
•Diagnosis of exclusion
•Advanced liver disease with elevated creatinine without other apparent causes
•Prerenal cause
-Vasodilation in splanchnic circulation
-Decreased intravascular volume
-Renal angiotensin release
-Decreased renal perfusion, GFR
Type I- rapid decline in renal function; median 2- week survival
Type II- slow progression
slide 25
What is the difference between the Child Pugh and MELD scores and what specifically are they used for?
•Child pugh- Albumin, Bilirubin, PT, ascites, encephalopathy; grades overall hepatic function, chronic liver disease
•MELD- Serum bilirubin, creatinine, INR (logarithms); includes Serum Na if MELD score >12- elevates transplant priority.; MELD- severity of liver disease.
slide 17
Column A
Column B
A. Pain that worsens on inspiration, indicating gallbladder disease
B. Infection or inflammation of the gallbladder often caused by obstruction
C. Involves radionuclide material to assess gallbladder function
D. Females, advanced age, rapid weight loss, and pregnancy
E. RUQ tenderness, fever, leukocytosis, and nausea
F. Possible rupture or necrosis of the gallbladder
1 - B
2 - A
3 - C
4 - D
5 - E
6 - F
slide 37
Column A
Column B
A. An anastomosis of the esophagus to the jejunum
B. Gastric carcinoma or ulcer disease
C. Risk of DVT/PE or anastomotic leak
D. A type of partial gastrectomy involving the remaining stomach and duodenum
E. A type of partial gastrectomy involving the remaining stomach and jejunum
F. Consideration of neuraxial anesthesia
Answer Key:
1 - D
2 - E
3 - A
4 - B
5 - C
6 - F
slide 60
Which of the following medications is indicated in the blue dye protocol for sentinel node mapping during breast surgery?
A) Toradol
B) Diphenhydramine
C) Nondepolarizing muscle relaxants
D) Morphine
B) Diphenhydramine
slide 84
Describe interventions that a CRNA can do to minimize blood loss during liver resection.
•surgical interruption of hepatic blood flow (pringle maneuver)
•Lowering CVP to reduce blood loss
•Replacing high volume blood loss
Slide 31
What is the most common cause of hepatitis, and how are the different types transmitted.
Most common cause: Alcohol
A & E: fecal-oral transmission
B,D,C: body fluids, disruption of cutaneous barriers
Outside the US hep D coexists with Hep B
slide 21
What are the main causes, symptoms, hallmark sign, and the most important medical management of Acute pancreatitis?
common cause: ETOH abuse, and Gallstones;
Hallmark sign: elevated serum amylase;
Symptoms: Excruciating, unrelenting, mid epigastric pain
Medical management: aggressive fluid and electrolyte resuscitation.
Slide 43-44
A patient diagnosed with malignancy in the middle and lower third of the esophagus is scheduled for esophagectomy. Which of the following statements is true regarding the surgical approaches, intraoperative considerations, and postoperative care for this procedure?
A) The left thoracoabdominal approach requires the patient to be placed in a supine position, while the transhiatal approach involves both abdominal and neck incisions with the patient in a left lateral position.
B) A double-lumen tube (DLT) is required for all surgical approaches, and patients must have their pulmonary function tests (PFTs) assessed prior to the procedure to ensure they can tolerate one-lung ventilation.
C) Postoperatively, patients typically spend 1-2 days in the ICU, with common complications including respiratory alterations, anastomotic leak/stricture, and recurrent laryngeal nerve (RLN) injury.
D) Preoperative management includes administering heparin at a dosage of 10,000 U SQ, and epidural analgesia is contraindicated in all patients undergoing this procedure.
C) Postoperatively, patients typically spend 1-2 days in the ICU, with common complications including respiratory alterations, anastomotic leak/stricture, and recurrent laryngeal nerve (RLN) injury.
slide 55-56
What is one of the common complications associated with mastectomy with reconstruction?
A) Hypertension
B) Flap necrosis
C) Osteoporosis
D) Allergic reactions to anesthesia
B) Flap necrosis
slide 85
Within a CRNA’s role, what are three ways to improve surgical access to the gallbladder during laparoscopic/robotic cholecystectomy?
Muscle relaxation during case
Positioning- supine, reverse trend, R side slightly elevated
Surgical exposure- avoid N2O, OG tube for stomach decompression
slide 39
What is the TIPS procedure indicated for and what are the anesthetic implications?
•Procedure done in IR for management of esophageal varices, or refractory ascites, may be a short term intervention for hepatorenal syndrome.
•Best performed under GA: Airway protection is likely a priority in patients with ascites and recent esophageal bleeding.
•Anesthetic considerations for advanced liver disease apply in these cases.
•Patients undergoing TIPS are very sick. Patients may have coagulopathy and large volume blood loss is possible. Blood products including packed red blood cells, fresh frozen plasma, and platelets should be available.
slide 34
What is the Whipple procedure and why would it be indicated?
Involves removal of distal stomach, entire duodenum, pancreatic head and neck, Gallbladder, and distal hepatic biliary tree.
indicated for tumors of the pancreatic head.
Slide 47
True or False: Post gastrectomy syndrome can occur in an estimated 25-50% of patients following gastric resection, and management includes a diet high in protein and low in carbohydrates, as well as monthly B12 injections.
True
slide 62
Which analgesic medication should be avoided in breast surgery?
Toradol
slide 84
•When is it acceptable to use a laryngeal mask airway in patients with a history of gastroesophageal reflux disease?
1- when GERD is well controlled. Continue use of antacids through day of surgery, supplement with histamine blockers and Metoclopramide.
slide 52