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Exam I: Full Stomach Flashcards

1
Q

What percent mortality occurs with aspiration?

A

5%

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2
Q

What reasons lead to higher risk of aspiration?

A
  1. Gi obstruction
  2. NPO failure
  3. Alc
  4. Trauma
  5. Medications that cause delayed gastric emptying ( narcotics)
  6. Extremes of age
  7. Pregnancy
  8. Parkinson’s disease level moreso w/ levodopa
    9 emergency surgery (3 - 4x)
  9. Night surgery (6x)
  10. Light or inadequate anesthesia
  11. ASA 4 or 5
  12. High spinal (can cause hypotension, or lose control of airway, vomiting with NMB)
  13. Difficult airway
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3
Q

What are some physiologic
Risk factors for aspiration?

A

l. Increased Justin fluid volume (gfv)
2. Delayed gastric emryptying
3. Impaired protective physiologic mechanisms (LES & UES)
4. Loss of airway protective reflexes

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4
Q

What are some risk factors that qualify as “full stomach”?

A
  • Intestinal Obstruction (SBO)
  • Drugs (opioids, anticholinergics)
  • Pregnancy (esp. 3rd)
  • Diabetes (neuropathy) central vs peripheral
  • Sympathetic stimulation (stress response) trauma, acute pain, anxiety
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5
Q

What are determinants of morbidity and mortality with regard to aspiration?

A
  1. PH (2.5)
  2. GFV aspirated directly (more is likely worse - 25cc?)
  3. Increased bacterial density
  4. Solid material (particulate)

BLOOD and DIGESTIVE ENZYMES do not appear to induce chemical pneumonitis

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6
Q

What variables are important to consider perioperatively to optimize the “‘full-stomach” patient?

A
  1. Type of anesthetic
  2. Pt comorbidities (ASA 3 or 4)
  3. Characteristics of aspirate
  4. NPO Status (recent meal, drink, alcohol)
  5. Gastric Insufflation (mask ventilation)
  6. Acid Hypersecretion (Hypoglycemia, alcohol, gastric secretion)
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7
Q

What forms the border between the stomach and the esophagus?

A

Lower Esophageal Sphincter

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8
Q

How do we calculate the Barrier Pressure?

A

BP = LES Pr. - Gastric Pr (IGP)

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9
Q

What is the normal gastric pressure?

A

<7 mmHg

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10
Q

What is the purpose of holding cricoid pressure?

A

Prevent the passive regurgitation of gastric contents

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11
Q

______ hernia is often associated with decreased LES tone (and therefore increased risk of aspiration).

A

Hiatal

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12
Q

Factors that increase Lower esophageal Barrier pressure:

A
  1. Dopaminergic antagonist
  2. Metoclopramide
  3. Beta Adrenergic Antagonist
  4. GI cholinergic agonists
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13
Q

What muscle acts as the functional Upper Esophageal Sphincter?

A

Cricopharyngeus Muscle

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14
Q

What anesthetic agent does NOT decrease UES tone in low doses?

A

Ketamine

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15
Q

What are three challenges full stomach patients present?

A
  1. Prevention of gastric regurgitation
  2. Prevention of pulmonary aspiration
  3. Appropriate airway management
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16
Q

4 criteria for creating “safe anesthetic management plan” for reducing pulmonary aspiration in full stomach patients:

A
  1. ID patients at risk for gastric regurgitation and pulmonary aspiration
  2. Utilizing NPO guidelines
  3. Implementing prophylactic pharmacological therapies
  4. Applying appropriate airway management techniques that may reduce pulmonary aspiration risk
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17
Q

Presence of bilious secretions or particular matter in the tracheobronchial tree

A

Aspiration

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18
Q

Time frame for aspiration risk

A

Pre-op - 2 hours Post op

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19
Q

3 ways of diagnosing aspiration

A
  1. Direct vision
  2. Bronchoscope
  3. New infiltrates from pre-op X-ray
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20
Q

Most risk for aspiration occurs during ____

A

Indication

however risk still remains at emergence

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21
Q

Clinically, during the first two hours after aspiration occurs, by much should we expect SpO2 to decline?

A

10%

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22
Q

What is an approximate aspiration mortality rate according to cited study in lecture?

A

5%

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23
Q

What approximate % of patients may appear asymptomatic the following 2 hours after aspiration?

A

2/3

Better Health Group

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24
Q

According to aspiration study, what fraction of patients ended up on the ventilator?

A

1/3

Poor Health Group

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25
According to aspiration study, if patients ended up ventilator for >24 hours, what was the mortality rate?
50%
26
Risks of High Aspiration: *might expect/can be planned for*
1. GI Obstruction 2. NPO Failure 3. ALC 4. Trauma (decreased PS tone = delayed gastric emptying) 5. Rx that delay GE (gastric emptying) = narcotics (opioid receptors present in GI tract) 6. Extremes of age 7. Pregnant (particularly 3rd tri. & those in labor) 8. Parkinson’s
27
Trauma patients will have **increased/decreased** ICP.
Increased
28
Why do elderly have higher risk of Aspiration?
Attenuated cough & gag reflex
29
Reason Parkinson’s causes increased aspiration risk?
Delayed gastric emptying *worse if on **Levodopa**: increases Dopamine levels —> slows GI motility & decreases LES tone*
30
Risks for higher aspiration: *not NOT expect/unplanned for*
1. Emergency surgery 2. PM surgery 3. Light/Inadequate Anesthsia 4. ASA 3+ 5. DA 6. High Spinal
31
Why is a high spinal associated with increased aspiration risk?
1. Impaired cough reflex 2. Difficulty Swallowing 3. Vomiting associated with sympathetic blockade - Induced hTN (Iatrogenic = something we cause)
32
*Physiologic* risk factors for aspiration in the peri operative environment
1. Increased GFV (gastric fluid volume) 2. DGE (Delayed gastric emptying) 3. Impaired protective physiologic mechanisms (LES & UES tone) 4. Loss of Airway protective reflexes *these are the actual problems that increase risk of aspiration, as opposed to the disease processes (Neurological, Neuromuscular, Opioids, etc.) that cause the problems*
33
Patients that meet any of the aspiration risk factors are said to be ____ patients
“Full Stomach”
34
Why are pregnant patients at increased risk of aspiration?
- architectural changes that create increased pressure on LES - Progesterone decreases LES - increased Gastrin = increases GFV
35
Which diabetic neuropathy causes the greatest ROA (risk of aspiration): Central vs Peripheral
Central (i.e., Dx: gastropheresis) *although peripheral neuropathic patients are still at increased ROA*
36
Reason Ozempic or Trulicity causes ROA concerns?
Increased secretion of Gastrin = Increases GFV Tk
37
What is the condition called when a patient aspirates into the lung and inflammation occurs?
Pneumonitis
38
What is caused by pneumonitis resulting from aspiration?
- Atelectasis: decreased surface area; Impaired ability of the lung to exchange oxygen, leading to hypoxemia, which further leads to hypoxia of tissues. - Edema: increased thickness; may occur as well from aspirated fluids, which will also impede oxygen exchange
39
What are the 4 determinants of morbidity & mortality with respect to aspiration?
1. PH <2.5 2. GFV >25mL 3. Bacterial density 4. Solid particulate *Blood & Digestive Enzymes do not appear to induce chemical pneumonitis*
40
What may occur if 2/2 to aspiration, an airway (e.g., bronchiole) becomes blocked?
Atelectasis
41
What may prevent the lung from collapsing completely?
Its constituents: - 100% oxygen = eventual complete collapse (as all will get picked up by RBC) - Nitrogen & other inert gases = will not get picked up by RBC
42
Abuse of drugs such as alcohol and/or marijuana can lead to what type of chronic condition?
Hyperemesis
43
What is the normal resting LES pressure
15-25 mmHg higher than intragastric pressure
44
What does the UES separate?
Upper esophagus and hypopharynx
45
Hiatal hernia decreases LES tone by ____ mmHg
10 mmHg *study showed 28 vs 17mmHg*
46
A distended stomach has an approximate intragastric pressure of ____ mmHg
35 mmHg (Normal = <7mmHg)
47
Dopaminergic Agonists, Beta Agonists, Ca-Channel Blockers & Anticholinergics **increase/decrease** LES tone.
Decrease
48
Dopaminergic Antagonists, beta Antagonists (blockers) & GI Cholinergic agonists increase/decrease LES tone.
Increase
49
VA increase/decrease LES tone.
Decrease
50
Besides Succs, what other MR increase LES tone?
Pancuronium
51
LES Tone Table/List
52
What MR does NOT alter UES tone?
Ketamine *Often mixed with Propofol and ran as infusion* *Provides sedation, analgesia* *Respiration drive preserved*
53
4 types of Laryngeal-Pharyngeal Protective airway reflexes
1. Apnea with laryngospasm 2. Coupling 3. Expiration 4. Spasmodic Panting
54
Conditions that cause loss of L-P airway reflexes
1. ALC 2. CNS-depressants 3. Cerebral Hemorrhage of Infarct 4. Neurological Dz (MS, Gillian-Barre, Cerebral Palsy, Parkinson’s) 5. NMD (MD, MG) 6. ETOH 7. Anesthetic agents that decrease UES tone
55
Describe how H2 blockers work?
- block histamine ligand from binding to histamine receptors - therefore, gastric acid is not produced *(histamine causes an increase in gastric acid secretion)* - this effectively increase the pH to a more optimal level
56
T/F: there is conclusive data that show evidence of improved outcomes for aspiration-risk patients who were prophylactically administered PPIs, H2 Blockers and antacids.
FALSE
57
Routine placement of preoperative gastric tubes is not recommended for patients with:
- small bowel obstruction (SBO) - gastric outlet obstruction - cardiac patients (ischemic risk)
58
In situ presence of gastric tube during indication provides us what opportunity?
Decompress the stomach ahead of time prior to induction (decreases aspiration risk)
59
With regard to inflatable gastric cuffs, What location is considered safest; however, further testing is still needed.
Gastric-Cardia (just below gastric-esophageal connection)
60
What type of gastric tube is able to left in post-extubation?
NG tube
61
Salem Sump is a ____
NG tube
62
Patients at a high risk for aspiration may be indicated for a/an ____ intubation.
Awake
63
Techniques to perform an awake intubation:
1. Sedation: mild sedation (versed) 2. Analgesia - Opt 1 - LA in pt airway: spray above cords/jelly to base of tongue - Opt 2 - bilateral block of Internal Branch of **SLN** 3. dry out airway secretions (Glycopyrrolate IM or IV) 4. Oxygenation: NC/modified NPA or simple mask
64
What is the goal of RSI
Minimize time airway is unprotected
65
What element converts RSI to modified RSI?
Addition of gentle PPV
66
Gold standard cricoid pressure
44 N
67
Cricoid pressure in theory is designed to stop ____ regurgitation of contents
Passive (Not active, which is why we release CP when pt actively aspirates)
68
Most common lung site for infiltrate
Right lower lobe
69
Coughing due to ____ can cause aspiration
Light anesthesia *associated with LMA aspiration*
70
Because prevention of hypoxemia trumps prevention of aspiration, what device, while contraindicated for pts with ROA, is permissible?
LMA
71
Which LMA allows for suctioning?
ProSeal LMA
72
What size gastric tube can be used for suctioning with the LMA ProSeal?
14Fr
73
Which LMA allows for blind intubation
Fastrach (size 8 ETT)
74
Besides allowance of suctioning, what is another important feature about the LMA ProSeal?
- It offers higher ventilation pressures - Provides more effective seal than cLMA
75
Procedure for observed aspiration/passive reflux
- suction contents from oropharynx & hypopharynx - positioning: (1) turn pt head laterally (2) place in Trendelenberg
76
Is routine bronchoscopy indicated for observed/passive reflux?
No, unless significant lower airway obstruction
77
What have studies shown with regard to bronchial lavage for patients who have aspirated?
- Proven waste of time and unnecessary - Excess fluid could be doing more damage
78
Bronchial secretions ____ aspirated acid within minutes.
Neutralize
79
What is the main goal of pulmonary aspiration management?
Restoring pulmonary function to normal ASAP
80
Tx. Of pulmonary aspiration:
Mild: face mask O2 More Severe: Bronchodilators, CPAP, High FiO2, wean Severe ETT: ARDS management
81
When are prophylactic antibiotics and steroids indicated with regard to aspiration
Only if there is active infection
82
Extubation criteria for aspiration risk pt:
- 4/4 sustained tetany - BETTER with *sustained head lift* - awake & conscious - responding to commands - *If DA, consider Extubating with Bougie* (allows for rapid reinsertion of ETT if pt loses control of airway; can remove later in PACU) **Deep extubation is contraindicated**

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