EDAIC Hepatic, Renal and Endocrine Anesthesia 1 — Questions and Answers
Question 1: Which volatile anesthetic agent is considered MOST hepatotoxic and carries the highest risk of immune-mediated fulminant hepatic necrosis?
- Isoflurane
- Sevoflurane
- Desflurane
- Halothane (Correct answer)
Correct answer: Halothane
Halothane undergoes extensive reductive and oxidative hepatic metabolism, producing reactive intermediates that trigger immune-mediated hepatocellular necrosis (halothane hepatitis) at an incidence of ~1:10,000.
Question 2: In a patient with end-stage liver disease, the volume of distribution of highly protein-bound drugs is most likely to:
- Decrease due to reduced hepatic blood flow
- Increase due to hypoalbuminemia increasing free drug fraction (Correct answer)
- Remain unchanged
- Decrease due to ascites reducing extracellular fluid
Correct answer: Increase due to hypoalbuminemia increasing free drug fraction
Hypoalbuminemia in liver failure increases the unbound (free) fraction of protein-bound drugs, effectively increasing their volume of distribution and pharmacodynamic effect.
Question 3: The hepatic artery supplies approximately what percentage of total hepatic blood flow?
- 10%
- 25% (Correct answer)
- 50%
- 75%
Correct answer: 25%
The hepatic artery provides approximately 25% of total hepatic blood flow but delivers about 50% of hepatic oxygen supply due to its high oxygen content.
Question 4: During liver transplantation, the anhepatic phase is associated with which hemodynamic change?
- Increased cardiac output from portal hypertension relief
- Hypotension due to inferior vena cava (IVC) occlusion and reduced venous return (Correct answer)
- Hypertension from systemic vascular resistance increase
- Tachycardia from sympathetic stimulation only
Correct answer: Hypotension due to inferior vena cava (IVC) occlusion and reduced venous return
Clamping the IVC during the anhepatic phase dramatically reduces venous return to the right heart, causing significant hypotension that may require venovenous bypass or careful fluid management.
Question 5: Which coagulation abnormality is MOST commonly seen in advanced liver disease?
- Elevated factor VIII levels
- Decreased production of vitamin K-dependent factors II, VII, IX, X (Correct answer)
- Thrombocytosis from splenic sequestration reversal
- Elevated fibrinogen
Correct answer: Decreased production of vitamin K-dependent factors II, VII, IX, X
The liver synthesizes clotting factors II, VII, IX, and X (vitamin K-dependent); advanced liver disease impairs their production, prolonging PT/INR.
Question 6: Succinylcholine duration of action is prolonged in severe liver disease primarily because of:
- Reduced renal clearance of succinylcholine
- Decreased plasma pseudocholinesterase production by the liver (Correct answer)
- Accumulation of toxic metabolites
- Increased acetylcholine receptor sensitivity
Correct answer: Decreased plasma pseudocholinesterase production by the liver
Plasma pseudocholinesterase (butyrylcholinesterase) is synthesized by the liver; its deficiency in hepatic failure slows succinylcholine hydrolysis and prolongs neuromuscular blockade.
EDAIC Hepatic, Renal and Endocrine Anesthesia 1
Which volatile anesthetic agent is considered MOST hepatotoxic and carries the highest risk of immune-mediated fulminant hepatic necrosis?