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Anaesthesiology
The Liver Surgery and Anesthesia
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
9 sections · 198 slides
Overview
- Scope and core messages
The healthy liver
- Size, position and functional unit of the liver
- Blood and bile flow through the liver lobule
- Dual blood supply and portal pressure
- Hepatic arterial buffer response
- Lobular zones and Kupffer cells
- Carbohydrate and fat metabolism in the liver
- Protein and clotting factor synthesis
- Ammonia handling and urea formation
- Bile formation, enterohepatic circulation and cholestasis
- Liver, gallbladder and bile duct anatomy
- Liver regeneration
- Vessels branching inside the liver
Measuring liver function
- What AST and ALT actually measure
- The AST to ALT ratio
- Markers of obstructed bile flow
- Bilirubin fractions and the ceiling in obstruction
- Albumin, prothrombin time and INR as tests of synthesis
- Research tests and reading the panel as a pattern
- Ancillary tests for specific diagnoses
- Blood tests and the differential diagnosis of hepatic dysfunction
- Ultrasound, plain films and radioisotope scanning
- Computed tomography and magnetic resonance imaging
- Cholangiography, ERCP and liver biopsy
Liver diseases
- Burden of liver disease and the anatomical divide
- Hepatocellular versus biliary disease
- Acute liver failure: definition, causes and outcome
- Initial assessment of suspected acute liver failure
- Initial laboratory panel in acute liver failure
- Initial laboratory analysis of suspected acute liver failure
- Initial laboratory analysis of suspected acute liver failure (continued)
- Systemic effects and encephalopathy grading
- Grades of encephalopathy
- Mechanism of cerebral oedema in liver failure
- Contributors to oedema and ammonia-lowering therapy
- Reducing cerebral oedema in acute liver failure
- Steroids, antibiotics and the cerebral perfusion target
- Monitoring intracranial pressure in acute liver failure
- Intracranial pressure management protocol
- Prognostic models in acute liver failure
- King's College selection criteria for liver transplantation by cause of acute liver failure
- Bleeding risk and factor concentrates in acute liver failure
- Hypotension in acute liver failure
- The hepatitis viruses and how they present
- Hepatitis A and hepatitis B
- Hepatitis D and hepatitis C
- Alcoholic hepatitis: features and treatment
- Mallory hyalin in alcoholic liver disease
- Drug-induced liver injury
- Mechanisms of drug-induced liver injury
- Halothane and the National Halothane Study
- The two forms of halothane hepatitis
- Metabolism and hepatitis risk of halogenated agents
- Liver disease in pregnancy and hyperemesis gravidarum
- Intrahepatic cholestasis of pregnancy
- Preeclampsia, HELLP syndrome and its laboratory findings
- Hepatic injury in HELLP syndrome
- Management of hepatic complications in HELLP
- Acute fatty liver of pregnancy
- Comparing the pregnancy-specific liver diseases
- Distinguishing intrahepatic cholestasis of pregnancy, HELLP syndrome and acute fatty liver of pregnancy
- Distinguishing intrahepatic cholestasis of pregnancy, HELLP syndrome and acute fatty liver of pregnancy (continued)
- Distinguishing intrahepatic cholestasis of pregnancy, HELLP syndrome and acute fatty liver of pregnancy (continued)
- Distinguishing intrahepatic cholestasis of pregnancy, HELLP syndrome and acute fatty liver of pregnancy (continued)
Cirrhosis and portal hypertension
- Chronic liver disease burden and portal hypertension thresholds
- Development of cirrhosis
- Nodular surface of a cirrhotic liver
- Haemostasis in liver disease and why PT misleads
- Rebalanced haemostasis and thrombosis risk
- Cholestatic coagulopathy and dysfibrinogenemia
- Thrombocytopenia and thrombin generation in cirrhosis
- Fibrinolysis in end-stage liver disease
- DIC and accelerated intravascular coagulation in liver disease
- The hyperdynamic circulation of cirrhosis
- The four components of cirrhotic cardiomyopathy
- Cirrhotic cardiomyopathy and coronary artery disease
- Diastolic dysfunction, autonomic neuropathy and QTc
- Cardiac testing limits and renal dysfunction in cirrhosis
- Non-hepatorenal kidney disease in cirrhosis
- Neurohormonal activation in cirrhosis
- Nephrotoxic drugs and assessing volume in cirrhosis
- Hepatorenal syndrome: frequency and precipitants
- HRS-AKI and HRS-CKD
- Why upstream therapy works, and combined transplantation
- Treating hepatorenal syndrome
- Breathlessness in liver disease and orthodeoxia
- Hepatopulmonary syndrome: criteria and detection
- Types of intrapulmonary vascular dilatation
- Mechanism of hypoxaemia in hepatopulmonary syndrome
- Hepatopulmonary syndrome outcome and POPH definition
- Criteria for portopulmonary hypertension
- POPH epidemiology and transplantation thresholds
- Screening and confirming portopulmonary hypertension
- Drug therapy for portopulmonary hypertension
- Hepatic encephalopathy and its differential diagnosis
- Diagnosing overt hepatic encephalopathy
- Pathogenesis of hepatic encephalopathy
- Searching for a precipitating factor
- Precipitating factors in hepatic encephalopathy
- Precipitating factors in hepatic encephalopathy (continued)
- Lactulose in hepatic encephalopathy
- Protein intake and zinc in hepatic encephalopathy
- Ascites and the serum-ascites albumin gradient
- Treating ascites and correcting sodium safely
- Refractory ascites and albumin replacement
- TIPS and peritoneovenous shunting for ascites
- Spontaneous bacterial peritonitis
- Formation of varices
- Esophageal varices and endoscopic banding
- Measuring portal pressure and diagnosing varices
- Management of acute variceal bleeding
- Hepatocellular carcinoma
- Treatment options in hepatocellular carcinoma
- Nonalcoholic fatty liver disease and steatohepatitis
- Biliary obstruction and hypercoagulability
- Kidney injury in cholestasis
- Primary biliary cirrhosis and primary sclerosing cholangitis
- PSC complications and the preoperative history
Preoperative assessment
- Physical signs of active liver disease
- Against routine preoperative liver testing
- Substantial enzyme elevation and acute hepatitis
- The Child-Turcotte-Pugh classification and its scoring
- Modified Child-Pugh score
- Mortality by Child class
- The MELD score and its predictive accuracy
- MELD score formula
- Mortality per MELD point
- Beyond MELD: extra predictors and the VOCAL-Penn score
- MELD thresholds for surgical decision-making
- Medical optimisation and viscoelastic coagulation testing
- Operative site and cumulative risk factors
- Laparoscopic surgery and preoperative TIPS in cirrhosis
Intraoperative management
- Monitoring and vascular access in liver disease
- Neuraxial and regional technique in liver disease
- Volatile anesthetics and hepatic blood flow
- Reactive metabolites and repeat exposure
- Sevoflurane and cross-sensitisation
- Nitrous oxide and intravenous anesthetics
- Opioids in liver disease
- Hepatic drug clearance and protein binding
- Extraction ratio and its consequences
- Pharmacodynamic sensitivity and organ-independent blockers
- Induction agents and neuromuscular blockers
- Vasopressor responsiveness and the TIPS procedure
- Albumin in volume resuscitation
- Transjugular intrahepatic portosystemic shunt
- Anesthesia and complications of the TIPS procedure
- History of liver surgery
- Couinaud segmental anatomy of the liver
- Mortality and technique in hepatic resection
- Blood loss control during hepatic resection
- Ischaemic preconditioning versus intermittent clamping
- Air embolism and coagulation after liver resection
- Analgesia and evolving techniques after liver resection
Postoperative liver dysfunction
- Postoperative liver dysfunction: presentation and time course
- Hepatic hypoxaemia and bilirubin load after surgery
- Lead-in to the causes of postoperative liver dysfunction
- Causes of postoperative liver dysfunction
- Unconjugated hyperbilirubinemia after surgery
- Conjugated hyperbilirubinemia and cardiac surgery in cirrhosis
- Causes of hyperbilirubinemia
- Site of surgery and renal failure as risk factors
- Mortality after hepatic resection by underlying liver state
Putting it together
- Timing of elective surgery in liver disease
- Where to operate and what technique to choose
- Ten facts to carry away
- Further facts to carry away
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition