Exam 2: GI and Liver Flashcards
Pre-op restriction on clear liquids:
2 hours
Pre-op restriction on breast milk:
4 hours
Pre-op restriction on light meals, milk, or formula:
6 hours
Pre-op restriction on heavy meals:
8 hours
Pre-op restriction on sips of water for meds:
1 hour
Patients who are aspiration risks (8):
Age extremes ( 70) Ascites Hiatal hernia/GERD/esophageal surgery Mechanical obstruction Metabolic disorders Neurologic diseases Pregnancy Prematurity
AAHMMNPP
Four greatest risks for aspiration:
Pregnant
Morbidly obese
Hiatal hernia
Preoperative anxiety
Aspiration prophylaxis:
H2 receptor antagonists
Sodium citrate/Bicitra
Metoclopramide/Reglan
PPI (i.e. omeprazole)
Use of H2 blockers pre-op:
Best given night before & 45-60 minutes pre-op
Famotidine: best result
Also cimetidine, ranitidine
Indications, MoA, and contraindications for pre-op metoclopramide:
Dopamine antagonism ↑ pressure on LES which speeds gastric emptying
Prevents/alleviates N/V
CONTRAINDICATED in obstruction!!
MoA, dose, and timing of sodium citrate pre-op:
30mL, 15 minutes before surgery to raise gastric pH (also raises volume, though)
Mendelson Syndrome characterized by:
Aspiration of > 25ml of gastric material at
Manifestations of Mendelson Syndrome:
Respiratory distress Bronchospasm Cyanosis Tachycardia Dyspnea
Tx for Barrett’s esophagus:
H2 blockers and PPIs
Nissen fundoplication
S/s of hiatal hernia:
Retrosternal discomfort
Burning after meals
+/- reflux
Tx of hiatal hernia:
Surgery
Risk factors for PUD:
H. pylori Age 45-60 Chronic NSAIDs ETOH Steroids
S/s of PUD:
Epigastric pain Vomiting Hematemesis/melena Abdominal tender/rigid Perforation
Tx of PUD:
H2 blockers and PPIs
Abx
Antacids
Tx of PUD:
H2 blockers and PPIs
Abx
Antacids
S/s of gastric ulcers:
Pain
Anorexia
Weight loss
Metabolic derangements
Important pre-op considerations for malabsorption syndromes:
Fluids and electrolytes
Vitamin K levels!
Important pre-op considerations for malabsorption syndromes:
Fluids and electrolytes
Vitamin K levels!
S/s of malabsorptions syndromes:
Weight loss Steatorrhea Diarrhea Anemia Fatigue Vitamin deficiency Dyscrasias Edema/ascites
Lab abnormalities in Crohn’s disease:
Deficiencies in magnesium, B12, phosphorus, folic acid, zinc, iron, postassium, albumin
Anemia
Carcinoid syndrome is:
Mild, non-metastatic cancer originating in the GI tract
Substances secreted by carcinoid cancers:
Bradykinin
Histamine
Serotonin
Dopamine
Skin signs of GI problems:
Jaundice Small veins Cracked lips Turgor (mostly fluid-related)
Useful GI labs:
Hgb/hct (fluid status)
Electrolytes
BUN/Cr
Serum albumin
Serum albumin range:
Should be > 4
Liver’s blood reservoir %:
10-15%
Risk factors for chronic liver disease:
Blood transfusions Jaundice Drugs/ETOH Meds/fish oil Travel hx Occupational hx
S/s of liver disease:
Bruising Anorexia Weight changes N/V Pain Itching GI bleeding
Two grading scales for liver dysfunction:
MELD
Child-Turcotte-Pugh
Factors in the Child-Turcotte-Pugh scoring system:
ABE APP: Ascites Bilirubin Encephalopathy Albumin PT/INR Primary biliary cirrhosis
Lab tests for liver function:
AAAA B CC NP: Ammonia AST/ALT Alk phos/GGT Albumin Bilirubin CBC Coags 5' Nucleotidase Prothrombin
Physical assessment for liver function:
Look for: Jaundice Ascites Dependent edema Asterixis
Anesthetic considerations for liver disease:
Often have enzyme induction and need ↑ sedatives
Hyperdynamic circulatory state
↑ levels of endogenous vasodilators like VIP
Liver disease effects on respiratory status:
Ascites impairs diaphragm movement and ↓ FRC
Factors dependent on Vitamin K:
II, VII, IX, X
2, 7, 9, 10
Absorption of Vitamin K depends on:
Bile salt excretion into the GI tract
Treatment of Hep B/C:
Interferon, ribavirin
Treatment of AI hepatitis:
Corticosteroids, AZT
Anesthetic considerations for hepatitis:
Aspiration precautions!
Look for s/s of encephalopathy, bleeding, ascites, etc.
Hours after ETOH withdrawal that tremors may be seen:
6-8 hours
Hours after ETOH withdrawal that seizures may be seen:
24 hours
Hours after ETOH withdrawal that DTs may be seen:
72 hours (but preceded by tremors, hallucinations, seizures)
Anesthetic considerations for cirrhosis:
Hyperdynamic circulation
↑ CO
↓ PVR
Clotting factors reduced in liver failure:
II, V, VII, IX, X
2, 5, 7, 9, 10
Factors dependent on Vitamin K:
II, VII, IX, X (2, 7, 9, 10)
Protein C, Protein S
Clotting factors reduced in liver failure:
II, V, VII, IX, X (2, 5, 7, 9, 10)
Mechanism of platelet dysfunction in liver failure:
Thrombopoietin is produced by the liver and signals for platelet production in the bone marrow
