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Liver anatomy, physiology and imporatance to anesthesia
 

Liver anatomy, physiology and imporatance to anesthesia

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Liver anatomy and physiology imporatnat considerations from anesthesia point of view

Liver anatomy and physiology imporatnat considerations from anesthesia point of view

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    Liver anatomy, physiology and imporatance to anesthesia Liver anatomy, physiology and imporatance to anesthesia Presentation Transcript

    • LIVER ANATOMY & PHYSIOLOGY DR. PRIYANKA Ruby Hall Clinic Pune
    • ANATOMY OF LIVER & BILIARY SYSTEM
      • 1.5 kg or 1% body wt
      • 5% in neonates
      • Holds 10 to 20 % of blood volume
      • Reservoir of blood
    • GROSS ANATOMY OF LIVER
    • LIGAMENTS OF LIVER
      • Ligamentum teres
      • Falciform ligament
      • Coronary ligament
      • Triangular ligament
    • LOBES OF LIVER
      • French (Couinaud) system
      • Each segment : own vascular supply & biliary drainage
      • Improved surgical outcome in neoplasm & traumatic liver injury
    • HEPATIC LOBULE
    • HEPATIC LOBULE
    • BLOOD SUPPLY
      • 25% of cardiac output
      • 1ml/ gm of liver
      • Hepatic artery : 25-30 % of blood flow & 45-50% of oxygen
      • Portal veins : valveless nutrient vessel , 70-75% blood flow, 50-55% of oxygen
    • SPLANCHNIC BLOOD FLOW
    • BLOOD FLOW IN LIVER
      • Terminal branches : sinusoids ( capillaries in liver)
      • Central vein : terminal hepatic venules
      • Hepatic veins
      • Inferior vena cava
    • HEPATIC SINUSOIDS
    • HEPATIC MICROCIRCULATION
    • HEPATIC ACINUS
      • ZONE 1 : PERIPORTAL
      • ZONE 2 : MIDZONE
      • ZONE 3 : PERICENTRAL
      • Receives blood that has gases & metabolites exchanged with zone 1 & zone2 G lutamine synthase ( urea)
    • INTRENSIC REGULATION OF BLOOD SUPPLY
      • 1 . Pressure flow regulation :
      • Myogenic , Not in portal system
      • Maximum in postprandial, Absent in fasting state
      • 2. Metabolic control :
      • Decrease in pH & O2 tension
      • 3. Hepatic arterial buffer response :
      • Adinosine (vasodilator)
    • EXTRENSIC REGULATION OF BLOOD FLOW
      • Neural control :
      • Splanchnic nerves ie postganglionic sympathetic T6-T11,vagus, phrenic nerves
      • Sympthoaderanal stimulation
      • Humoral control : HA( α 1 β 2 α 2) PORTAL( α )
      • Epinephrine - vasoconstriction
      • Dopamine – no influence
      • Glucagon - vasodilatation
      • Angiotensin 2 - vasoconstriction
    • FACTORS AFFECTING HEPATIC BLOOD FLOW
      • INCREASE IN HEPATIC BLOOD FLOW
      • Hypercapnia
      • Acute hepatitis
      • Supine posture
      • Food intake
      • Drugs : β Agonist
      • Phenobarbitone
      • Enzyme inducers
      • DECREASE IN HEPATIC BLOOD FLOW
      • IPPV
      • Hypocapnia
      • Hypoxia
      • Cirrhosis
      • α Stimulation
      • β Blocker
      • Halothane , volatile & anesthetics
      • Vasopressin
    • EFFECT OF VOLATILE AGENTS ON HEPATIC BLOOD FLOW
      • Halothane : Causes hepatic arterial constriction, microvascular vasoconstriction
      • Enflurane: Increase in hepatic vascular resistance
      • Isoflurane : Increase in microvascular blood velocity
      • Sevoflurane & Desflurane : Preservation of hepatic blood flow & function
    • EFFECT OF INTRAVENOUS AGENTS ON HEPATIC BLOOD FLOW
      • THIOPENTONE & ETOMIDATE : Hepatic arterial blood flow reduction, reduced cardiac output
      • KETAMINE : Little effect on hepatic blood flow
      • PROPOFOL : Significant splanchnic vasodilator
      • Increases both hepatic arterial & portal venous blood flow
    • REGIONAL ANESTHESIA & HEPATIC BLOOD FLOW
      • Reduction in hepatic blood flow in high spinal & epidural anesthesia
      • Secondary to hypotension
      • Reversed by vasopressors like dopamine, ephedrine
    •  
    • CARBOHYDRATES & PROTEIN METABOLISM
      • Protein synthesis
      • Albumin
      • Coagulation
      • Acute phase reactent
      • Hormone prcursors
      • Transport proteins
      • Protein catabolism
      • Ammonia -> urea
    • CARBOHYDRATE METABLOLISM
      • GLYCOGENESIS
      • GLYCOGENOLYSIS
      • 24-48 Hrs OF STRAVATION
      • GLUCONEOGENESIS
    • FATTY ACID SYNTHESIS & OXIDATION
    • BILE PRODUCTION
      • Bile acid production
      • Absorbtion
      • Transportation
      • Solubilizing effect on lipids
      • Activates lipases
      • Cholesterol synthesis
    • MICELLE
      • Micelle needed for absorption of
      • Cholesterol
      • Fat soluble vitamines
      • Lipids
      • Opioids : spasm of spincor of oddi , interfere with bile flow
    • COAGULATION & LIVER ACTIVATION
    • ERYTHROPOIESIS & HEME SYNTHESIS
      • 9-24 wks of gestation
      • Major organ till 2 yrs
      • Heme synthesis
      • 5 aminolevulinic acid
      • Prophyrias :
      • Barbiturates
      • Etomidate
      • Enflurane
    • BILIRUBIN METABOLISM
    • DRUGS METABOLISM
    • DRUGS EXCREATED THROUGH LIVER
      • EFFICIENTLY EXCRETED
      • Amitryptiline
      • Desipramine
      • Imipramine
      • Labetolol
      • Lidocaine
      • Meperidine
      • Metoprolol
      • Mophine
      • Pentazocine
      • Propranolol
      • Verapamil
      • Zydovudine
      • POORLY EXCRETED
      • Acetaminphen
      • Amobarbital
      • Aspirin
      • Clindamycin
      • Diazepam
      • Digitoxin
      • Ethanol
      • Penobatbital
      • Phenytoin
      • Tolbutamide
      • Warfarin
      • Tolbutamide
    • DETERMINANTS OF DRUG METABOLISM
      • Drugs inducers & inhibitors
      • Age ,Sex
      • Fever, Hypothyroidism
      • Halothane reduces blood flow & hence metabolism of fentanyl verapamil, propranolol ,warfarin, phenytoin
      • Ketamine induces own metabolism
    • ALCOHOL METABOLISM
    • IMMUNE FUNCTION
      • KUPFFER CELLS : 10%
      • Phagocytosis of bacteria & inflamatory mediators in splanchnic blood
      • Stellate cells :
      • Injury
      • Fibrosis
    • Endocrine function
      • Synthesis of Angiotensinogen
      • Thrombopoietin
      • Insulin like growth factors
      • Inactivates aldosteron,estrogen,ADH,androgens
      • T4 -> T3 or inactivated
    • LIVER DYSFUCTION
    • EFFECTS OF HEPATIC DYSFUNCTION OF ANESTHETIC DRUGS
      • Altered protein binding
      • Altered volume of distribution
      • Altered drug metabolism due to hepatocyte dysfunction
    • EFFECTS OF HEPATIC DYSFUNCTION ON ANESTHETIC DRUGS
      • Opioids: exaggerated sedative & respiratory depressant effect
      • Half life is almost doubled
      • Remifetanyl :
      • Synthetic opioid
      • Ester linkages
      • Rapid hydrolysis by blood, tissue esterases
    • EFFECTS OF HEPATIC DYSFUNCTION ON ANESTHETIC DRUGS
      • Sedative & hypnotic
      • Benzodiazepines : Duration of action increased
      • Thiopentone, etomidate propofol ketamine : Repeated doses & prolong infusion causes accumulation of drugs
      • Increases risk of hepatic encephalopathy
    • NEUROMUSCULAR BLOCKING DRUGS
      • Vecuronium, rocuronium, mivacurium :
      • Reduced elimination
      • Prolong duration of action
      • Specially with infusion & repeated doses
      • Atracurium & cisatracurium :
      • Nondependant of hepatic metabolism
      • Can be used without modification of doses in end stage liver disease
    • HALOTHANE HEPATITIS
      • 1 : 6000 , 1: 20,000
      • Mild : focal necrosis, self limited
      • Fluminant : repeated exposure, massive necrosis, mortality 50%
      • Trifluroacetyl(TFA) antibody formation
    • TAKE HOME MESSAGES
      • Liver major organ of metabolism
      • Liver dysfunction affects pharmacokinetics of anesthetic drugs
      • Anesthetic drugs affects liver function
      • Neuroaxial blocks : reduction in hepatic blood flow due to hypotension
      • Introperative hypotension, hypoxia, hypocapnia, use of hepatotoxic drugs in perioperative period can cause postoperative hepatic dysfunction
    • THANK YOU THANK YOU