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4East/SICU

Liver Transplant II

Acute Liver Failure

Immunosuppression

Inflammatory Bowel Disease

Breast Reconstruction

Liver Transplant Part I

*Please take the quiz below the video to receive credit.

Objectives

Understand liver failure physiology and the pre-transplant condition
Describe the management and common therapies used to support a patient with liver failure

Articles

Evolution in the understanding of the pathophysiological basis of portal hypertension: How changes in paradigm are leading to successful new treatments
Hepatorenal syndrome: Update on diagnosis and treatment

Lecture

Quiz

Liver Transplant Part I

Name*
First Last
1. Clinical manifestations of portal hypertension, including esophageal varices and GI bleeding, become increasingly common once the portal pressures reach what pressure?*
- a. 6-8mmHg
- b. 10-12mmHg
- c. 15-18mmHg
- d. Greater than 20mmHg
2. All of the following are used to calculate a MELD score except:*
- a. Creatinine
- b. Bilirubin
- c. INR
- d. Platelets
3. Thrombocytopenia in chronic liver disease is most commonly causes by which of the following:*
- a. Hypersplenism
- b. DIC
- c. Decreased production
- d. Infection
4. Management of chronic ascites may include all the following except:*
- a. Sodium restriction to less than 2g/day
- b. Dual diuretic therapy
- c. Scheduled albumin dosing
- d. Therapeutic paracentesis for symptom relief
5. Following paracentesis of greater than 5 liters, how much albumin should be given to the patient as replacement.*
- a. 2-3g/L
- b. 3-5g/L
- c. 6-8g/L
- d. 10g/L
6. True or FALSE: A normal ammonia level excludes hepatic encephalopathy*
- True
- False
7. Cirrhotic Cardiomyopathy is commonly characterized by all of the following features except*
- a. Ejection Fraction of less than 35%
- b. Fatigue and decreased exercise tolerance
- c. Ventricular hypertrophy and diastolic dysfunction
- d. Electrophysiological abnormalities including a prolonged QTc
- e. Autonomic dysfunction and vagal impairment
8. Medical treatment of hepatorenal syndrome may include all of the following except*
- a. Albumin transfusion
- b. Diuretics
- c. Vasoconstrictors
- d. Octreotide
9. Management of hepatic encephalopathy include all of the following except:*
- a. Lactulose
- b. Rifaxamin
- c. Fluid restriction
- d. Branched-chain amino acids
- e. All of the following may be used in the management of hepatic encephalopathy
10. Most frequent complications of a TIPS procedure include all of the following except*
- a. Encephalopathy
- b. Intra-abdominal hemorrhage
- c. Right heart Failure
- d. Worsening Liver Failure
- e. Acute renal failure

Liver Transplant Part II

*Please take the quiz below the video to receive credit.

Objectives

Understand surgical details of a liver transplant
Understand indications of good graft function and the methods to support it

Articles

Cirrhotic cardiomyopathy on the pre- and post-liver transplantation phase
Intensive care management of liver transplanted patients

Lecture

Quiz

Liver Transplant Part II

Name*
First Last
1. The form of liver failure most associated with cerebral edema and severe coagulopathy is:*
- a. Fulminant liver failure
- b. Alpha one antitrypsin deficiency
- c. NASH
- d. Autoimmune liver Failure
2. What level of steatosis is acceptable for a donor liver to be transplanted at UF Health?*
- a. Less than or equal to 20%
- b. Less than or equal to 30%
- c. Less than or equal to 50%
- d. Less than or equal to 60%
3. The recipient vena cava is left intact and the donor cava is connected to recipient hepatic veins in which transplant technique?*
- a. Piggy Back
- b. Bi-caval
- c. Cava to Cava
- d. Orthotopic
4. Delayed graft time is commonly seen with warm times greater than:*
- a. 30 minutes
- b. 45 minutes
- c. 60 minutes
- d. 90 minutes
5. If the bile duct is reconstructed using the choledocoduodenostomy technique, the NG tube is to remain in place for how many days following transplant*
- a. 3
- b. 4
- c. 5
- d. 6
6. A post-transplant functioning liver is identified by all of the following except:*
- a. Improving lactate
- b. Bile production
- c. Improving INR
- d. Improving mental status
- e. All of the above are indicators of a postoperative functioning liver.
7. The first hepatic ultrasound is obtained how soon following liver transplant*
- a. Within 1-3Hours
- b. At 24 hours
- c. At 3 days
- d. At 1 week
8. A HIDA scan done to identify postsurgical bile leak may be unreliable in the presence of what condition*
- a. Bile duct stent placement
- b. Biliary obstruction
- c. Cholestasis
- d. Roux-n-y biliary reconstruction
9. Following liver transplant, a CVP of ___________ is targeted during postoperative resuscitation to avoid post-transplant hepatic congestion.*
- a. Less than 3
- b. 3-5
- c. 6-8
- d. 8-10
10. When viewing a hepatic ultrasound following liver transplant, the hepatic artery waveform should have __________, and a resistive index of ________.*
- a. A tri-phasic appearance; 0.6-0.9
- b. A sharp upstroke; 0.6-0.9
- c. A sharp upstroke; 0.0.3-0.6
- d. Tardus Parvus; 0.3-0.6
- e. A tri-phasic appearance; 0.3-0.6

Acute Liver Failure

*Please take the quiz below the video to receive credit.

Objectives

Describe clinical, laboratory, and radiological features used to diagnose acute liver failure and determine etiology.
Assess severity of the patient with ALF and appropriate monitoring and immediate management.
Understand differences between ALF and acute on chronic liver failure.
Choose therapies to optimize support of the liver and other organ systems.

Articles

Management Problems in Liver Disease – Acute Liver Failure
Acetaminophen Overdose: What Practitioners Need to Know

Lecture

Quiz

Acute Liver Failure

Name*
First Last
1. Which of the following is a cause of acute liver failure?*
- a. Anti-tuberculosis drugs
- b. Hepatitis
- c. Chickenpox
- d. All of the above
2. NAC is highly effective at augmenting glutathione levels if given within 8-12 hours of acetaminophen overdose.*
- True
- False
3. A stable cirrhotic will NOT exhibit tachycardia, vasodilated hemodynamic circulation, and reduced baseline PMN’s.*
- True
- False
4. Which of the following laboratory tests is the most specific for liver function in acute liver failure?*
- a. AST
- b. ALT
- c. Creatinine
- d. Direct Bilirubin
5. Your patient presents with concern for acute liver failure. You calculate a Child-Pugh Score of 12. This means that your patient has which of the following?*
- a. Grade A-well compensated disease
- b. Grade B- significant functional compromise
- c. Grade C- decompensated disease
- d. Grade E- Early decompensation
6. Which medication is most commonly given to treat hyperammonemia in acute liver failure?*
- a. Lactulose
- b. Narcan
- c. Flumazenil
- d. L-arginine
7. Hepatorenal syndrome is a type of pre-renal failure that is responsive to fluid administration, often reversing with the administration of crystalloids.*
- True
- False
8. Portal Venous Thrombosis can occur without associated liver disease and can lead to Portal Hypertension.*
- True
- False
9. Which of the following findings is not associated with acute liver failure?*
- a. Jaundice
- b. coagulopathy
- c. Hypoglycemia
- d. Encephalopathy
- e. None of the above
10. I attest that I have listened to this lecture in its entirety and fully reviewed the research articles attached.*
- True
- False

Immunosuppression

*Please take the quiz below the video to receive credit.

Objectives

Define the classes of immunosuppressive agents with respect to their mechanism of action, pharmacokinetics, and adverse effects
Calculate dose conversions for immunosuppressive agents
Identify common drug interactions with immunosuppressive agents and design an appropriate therapeutic recommendation for said interaction

Articles

Immunosuppressive agents in solid organ transplantation: Mechanisms of action and therapeutic efficacy
Pharmacology of immunosuppressive medications in solid organ transplantation

Lecture

Quiz

Immunosuppression

Name*
First Last
1. All of the following are true of thymoglobulin use except:*
- a. Classified as lymphocyte-depleting polyclonal antibodies
- b. Has limited diffusion into peripheral tissues such as fat
- c. Carries a risk of inducing cytokine response syndrome
- d. Has a biological half life of about 90 days
- e. Associated with pancytopenia
2. True or False: Unlike inducing a patient with lymphocyte depleting antibodies, Basiliximab does not require premedication when given.*
- True
- False
3. All of the following classes of immunosuppressive medications may be used as maintenance immunosuppression therapy except:*
- a. Co-stiimulation inhibitors
- b. Calcineurin inhibitors
- c. mTOR inhibiotors
- d. DNA synthesis inhibitors
- e. Lymphocyte-depleting antibodies
4. Once tacrolimus is started following liver transplant, trough levels should be maintained as:*
- a. 3-5ng/mL
- b. 8-10ng/mL
- c. 20-25ng/mL
- d. 100-400ng/mL
- e. 600-800ng/mL
5. All of the following increase serum levels of calcineurin inhibitors except:*
- a. Diltiazem
- b. Fluconazole
- c. Azithromycin
- d. Grapefruit
- e. Protease inhibitors
6. The IV to PO (IV:PO) ratio of conversion for tacrolimus is which of the following?*
- a. 1:1
- b. 1:2
- c. 1:3
- d. 1:4
7. Which immunosuppressive medication offers a sublingual dosing option?*
- a. Sirolimus
- b. Basiliximab
- c. Tacrolimus
- d. Mycophenolate Mofetil
- e. Cyclosporine
8. Which class of immunosuppressive medications is associated with the possible complication of interstitial pneumonitis?*
- a. mTOR inhibitors
- b. DNA synthesis inhibitors
- c. Calcineurin inhibitors
- d. Co-stimulation inhibitors
9. PO dosing of calcineurin inhibitors is usually preferred to IV dosing due to which of the following:*
- a. Increased nephrotoxicity with IV dosing
- b. Binding of medication by polyvinylchloride tubing
- c. Higher rates of rejection in some organs with IV dosing
- d. A and B
- e. All the Above
10. Which immunosuppressive medication relies on enterohepatic recirculation and may be inhibited by poor absorption (cholestyromine) or by concomitant use with cyclosporine*
- a. Tacrolimus
- b. Mycophenolate Mofetil
- c. Sirolimus
- d. Azathrioprine
- e. Basiliximab

Inflammatory Bowel Disease

*Please take the quiz below the video to receive credit.

Objectives

Understand the types of inflammatory bowel disease (IBD) and complications associated with each
Describe appropriate surgical management strategies for patients with IBD
Discuss postoperative management and common complications of surgery in patients with IBD

Articles

Current Concepts and Controversies in Surgery for IBD
Surgery for inflammatory bowel disease

Lecture

Quiz

Inflammatory Bowel Disease Quiz

Name*
First Last
1. True or False: Ulcerative colitis can be cured with surgical resection?*
- True
- False
2. Which of the following complications would NOT prompt emergent surgical treatment for ulcerative colitis?*
- a. Toxic megacolon
- b. Perforation
- c. Hemorrhage
- d. Greater than 5 bowel movements a day
3. Which of the following is not true regarding emergent colorectal surgery in a patient with ulcerative colitis?*
- a. Most surgeries are rectal sparing initially with ileostomy formation as there is a higher incidence of pouch complications and anastomotic breakdown if patients are taking steroids
- b. The rectum must be mobilized to look for further disease involvement
- c. There is a higher incidence of pelvic sepsis if the rectum is mobilized intraoperatively
- d. All of the above are true
4. Which of the following is the most common complication associated with an Ileal pouch-anal anastomosis (IPAA)?*
- a. Pouchitis
- b. Pelvic sepsis
- c. SBO
- d. ileus
5. Which of the following is the most common area affected by Crohn's disease?*
- a. Terminal ileum
- b. Cecum
- c. Duodenum
- d. Mid-jejunum
6. In a Crohn's patient presenting with possible small bowel stricture on CT scan vs active inflammation, what diagnostic imaging can definitively diagnose stricture vs inflammation.*
- A. Push endoscopy
- B. Capsule endoscopy
- C. UGI series
- D. MRE
7. Which of the following considerations should be made prior to taking a patient with Crohn's to the OR with symptomatic small bowel strictures?*
- a. Patients should be medically optimized
- b. Minimal to no active disease should be present
- c. Nutritional status should be optimized
- d. All of the above
8. Which of the following would be a contraindication to stricturoplasty in Crohn's disease?*
- a. Previous small bowel resection
- b. Short gut syndrome
- c. Multiple strictures in a short segment of small bowel
- d. Non-phlegmonous fibrotic stricture
9. True or False: The literature largely agrees that patients taking Anti-TNF agents preoperatively are at an increased risk for developing infectious complications post operatively*
- True
- False
10. Initial management of a anal fistula in a Crohn's patient should include which of the following:*
- a. Fistulotomy
- b. Seton drainage
- c. Total colectomy
- d. Abx only

Breast Reconstruction

*Please take the quiz below the video to receive credit.

Objectives

Review the benefits and risks associated with using surgical free flaps for breast reconstruction
Describe the types of commonly used surgical flaps and how they differentiate from each other
Describe initial postoperative care of surgical free flaps and the most likely postoperative complications that could occur

Articles

Postoperative Care and Monitoring of the Reconstructed Head and Neck Patient
Abdominal perforator vs. muscle sparing flaps for breast reconstruction

Lecture

Quiz

Surgical Flaps

Name*
First Last
1. A transverse rectus abdominis myocutaneous (TRAM) flap uses which blood vessel for blood supply?*
- a. Deep inferior epigastric artery
- b. Sapheonous vein graft
- c. Internal mammary artery
- d. Superficial inferior epigastric artery
2. The most reliable flap for breast reconstruction used for large free flaps is a:*
- a. TRAM flap
- b. DIEP flap
- c. SIEA flap
- d. Gracilis flap
3. DIEP flaps are separated from TRAM flaps by which of the following?*
- a. No muscle is transferred with the flap
- b. A different artery is used for flap blood supply
- c. A different donor site of the abdomen is selected
- d. All of the above
4. Which abdominally based flaps carry the greatest complicated rate?*
- a. SIEA flaps
- b. TRAM flaps
- c. DIEP flaps
- d. Gracilis flaps
5. Postoperative care following a gracilis myocutaneous flap used for breast reconstruction include all of the following except:*
- a. Hip flexed with pillow under knee
- b. Incisional wound vac placed over the donor site
- c. Placement of an abdominal binder
- d. Doppler checks of surgical flap
6. Postoperatively free flaps should receive every hour monitoring and Doppler checks for how long*
- a. 12 hours
- b. 24 hours
- c. 36 hours
- d. 48 hours
7. All of the following may be routinely given as part of breast reconstruction postoperative care except:*
- a. Toradol 15mg
- b. Fluid bolus
- c. ASA 81mg daily
- d. Subcutaneous heparin 5000u BID
8. A flap that becomes pale or dusky with a diminished or absent Doppler signal would be largely concerning for which of the following?*
- a. Venous failure
- b. Arterial failure
- c. Flap infection
- d. Dehydration
9. A flap that seems to darken in color, becoming boggy and edematous would be largely concerning for which of the following?*
- a. Venous failure
- b. Arterial failure
- c. Flap infection
- d. Dehydration
10. Following formation of a thrombus within the arterial supply to a myocutaneous surgical flap, approximately how soon afterward does irreversible damage occur to the flap?*
- a. 1 hour
- b. 2 hours
- c. 3 hours
- d. 4 hours
- e. 5 hours

Paracentesis

*Please take the quiz below the video to receive credit.

Objectives

Describe common causes of ascites
Understand Pathophysiology of Ascites in Cirrhosis
Review anatomy relevant to selecting an appropriate paracentesis site
Understand the clinical indications to performing paracentesis
List the contraindications for paracentesis
Describe how to perform paracentesis
List common complications of paracentesis.

Articles

Pathophysiology and Prevention of Paracentesis-induced Circulatory Dysfunction: A Concise Review
Things We Do for No Reason™: Routine Correction of Elevated INR and Thrombocytopenia Prior to Paracentesis in Patients with Cirrhosis

Lecture

Quiz

Paracentesis

Name*
First Last
1. In a patient with Serum Ascites-Albumin Gradient of 1.4 which of the following should not be included in the differential?*
- a. Pancreatitis
- b. Cirrhosis
- c. Cardiac Failure
- d. Nephrotic Syndrome
- e. None of the Above
2. In which of the following patients is paracentesis NOT indicated?*
- a. A 44 y.o. male with no significant PMHx presenting to the Emergency Room with HR 65, RR 16, BP 105/82 for jaundice, abdominal “bloating” and recent 30-pound weight gain. Fluid present on Abd US.
- b. A 35 y.o. female after MCC with HR 105, RR 20, BP 110/63 and a positive FAST.
- c. A 56 y.o. male admitted to the ICU for evaluation for Liver Transplant with temp of 39.0C, HR 85, RR 16, BP 90/55, WBC of 21.0, and abdominal tenderness.
- d. A 47 y.o. female with HR 120, RR 35, SpO2 of 87%, and BP of 98/62 admitted for decompensated Liver Failure with known ascites despite TIPS.
- e. All of the Above should undergo Paracentesis
3. True or False: The INR should always be corrected prior to performing paracentesis.*
- True
- False
4. How much ascitic fluid must be present for a fluid wave to be present on physical exam?*
- a. 100 mL
- b. 1.5 L
- c. 3 L
- d. 10 L
5. Which of the following is not a relative contraindication to performing paracentesis?*
- a. Pregnancy
- b. Distended Bladder
- c. Primary Fibrinolysis
- d. Suspicion of Acute Surgical Abdomen
- e. Massive Ileus
6. True or False: The patient should be fasting prior to performing Paracentesis.*
- True
- False
7. When considering paracentesis site selection, which of the following are true? (select all that apply)*
- a. The LLQ is the preferred site.
- b. You should not attempt Paracentesis through a surgical scar.
- c. You should not attempt Paracentesis through suspected abdominal wall cellulitis.
- d. From the ASIS, the preferred site will be 2 finger breaths medial and 2 finger breaths cephalad.
- e. The CCM attending should approve the site prior to performing paracentesis.
- f. All of the above
8. True or False: When performing paracentesis, the Z Track Technique involves using the non-dominant hand to provide tension on the skin in a downward motion while using the dominant hand to insert the paracentesis needle at a 90-degree angle to the skin.*
- True
- False
9. During paracentesis, the patient develops hypotension and tachycardia. Which of the following interventions should be considered?*
- a. Albumin administration
- b. Vasopressors
- c. Acute Myocardial Infarction work up
- d. Crystalloid Administration
- e. A, B, and C
10. After Paracentesis, the patient experiences ongoing ascitic fluid leak. Which of the following interventions should be done?*
- a. Horizontal Mattress Suture
- b. Repeat Paracentesis to drain all ascites.
- c. Drain Placement through prior site.
- d. Ostomy bag placement over site for accurate I/Os.
- e. A and D

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