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Advanced Health Assessment > GI/Liver > Flashcards

GI/Liver Flashcards

1
Q

What are the guidelines for NPO status pre-operatively in a healthy patient?

A

no chewing gum or candy after midnight
clear liquids up to 2 hours before
breast milk up to 4 hours before
light meal, milk or formula up to 6 hours before

(only really applicable in ASA class 1 or 2 patients)

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2
Q

What are some factors that make a patient at high risk for aspiration?

A 
age extremes
ascites or ESLD
metabolic disorders like DM, ESRD or hypothyroid
hiatal hernia/GERD
mechanical obstruction like intestinal obstructions or pyloric stenosis
prematurity
pregnancy
obesity
neurologic disease
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3
Q

What kinds of patients are at the GREATEST risk of aspiration?

A

high anxiety pre-op
obesity
pregnancy (esp after 14 weeks)
hiatal hernia

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4
Q

What are some common treatments for aspiration prophylaxis?

A

h2 antagonists
sodium citrate (bicitra)
reglan
omeprazole

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5
Q

H2 Antagonists – special considerations?

A

act as competitive antagonists at the H2 receptors at the gastric parietal cells to decrease acid secretion

best if given the night before surgery and then repeated 1 hour before surgery

ex. cimetidine and famotidine

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6
Q

metoclopramide – special considerations

A

acts as a dopamine antagonist to increase pressure at the lower esophageal sphincter to speed up gastric emptying

prevent or alleviates N/V

CONTRAINDICATED in intestinal obstruction

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7
Q

sodium bicitrate (bicitra) – special considerations

A

its a non-particulate antacid used to raise gastric pH (30 mL of volume which may contribute to aspiration risk)

give it 15 minutes before surgery and it will last for 3 hours

not indicated if the patient has no risk factors for aspiration, per ASA

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8
Q

What are some physiologic risk factors for aspiration pneumonitis?

A

pH 25 mL in 70 kg patient

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9
Q

What are the manifestations of aspiration pneumonitis?

A

potentially the only sign intra-op might be a persistent desat with the tube definitely in the right place

bronchospasm, cyanosis, tachycardia, dyspnea

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10
Q

how are aspiration syndromes characterized?

A

by volume aspirated, type of material aspirated, pH of the material

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11
Q

What is the treatment for Barrett’s Esophagus?

A

H2 blockers, PPIs, nissen fundoplication

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12
Q

what are S&S of barrett’s esophagus?

A

dysphagia, reflux esophagitis, heartburn, LES dystonia, weight loss

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13
Q

How would you modify the anesthetic plan in the case of a patient with Barrett’s Esophagus?

A

prepare for an RSI

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14
Q

What are the S&S of a hiatal hernia?

A

retro-sternal discomfort

reflux after meals

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15
Q

What is the usual cause of peptic ulcer disease?

A

H. Pylori

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16
Q

What are some typical treatments for peptic ulcer disease?

A

H2 antagonists, PPIs, antimicrobial therapy, antacids

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17
Q

Who is at high risk for a peptic ulcer?

A

chronic NSAID use, age 45-60, ETOH

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18
Q

What are the S&S of peptic ulcer disease?

A 
vomiting blood
epigastric pain
abdominal tenderness and rigidity
perforation 
weight loss
anorexia
metabolic disturbances
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19
Q

What are some examples of malabsorption syndromes?

A

celiac’s disease
protein malabsorption syndromes
fat malabsorption syndromes
small bowel perforation or obstruction

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20
Q

What is the clinical significance of malabsorption syndromes?

A

metabolic disturbances that change electrolytes and fluid status

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21
Q

What are some S&S of malabsorption syndromes?

A 
unexplained weight loss
fatty stools
diarrhea
anemia
fatigue
Vit K deficient
bleeding
edema/ascites
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22
Q

What is the clinical significance of Crohn’s disease pre-anesthetically?

A

deficient in multiple vitamins and minerals such as B12, phosphorous, folic acid, zinc, iron, K+

hypoalbuminemia

anemia

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23
Q

What are the S&S of ulcerative colitis?

A 
intermittent bloody diarrhea
fever/malaise
anorexia
abdominal pain
weight loss
24
Q

What are some anesthetic considerations for a patient with large colon dysfunction, such as Crohn’s and uclerative colitis?

A

patient may be on chronic steroids and would require a stress dose pre or intra op

prepare for immune suppression r/t meds and higher infection risk

25
Q

What is carcinoid syndrome?

A

a small tumor that has originated in the GI tract or bronchi and will produce hormones that can be secreted in the blood and cause systemic effects

26
Q

What are some S&S of carcinoid syndromes?

A

cutaneous flushing, diarrhea, palpitations, bronchospasm, dyspnea, hypotension, hypertension, orthostasis

*may want to consider a 12 lead EKG if there are S&S of a dysrhythmia

27
Q

What is the problem with having a carcinoid syndrome?

A

the tumors secrete hormones such as bradykinin, serotonin, dopamine and and histamine

28
Q

What are some helpful lab values when taking care of a patient with severe GI or liver disease?

A

Hct, albumin, serum electolytes, BUN

29
Q

Nutritional deficiencies are associated with what poor outcomes?

A 
prolonged hospital stays
poor wound healing
higher infection rate
respiratory failure
death
30
Q

What is a relatively accurate indicator of malnutrition?

A

serum albumin

31
Q

What are some normal physiologic functions of the liver?

A 
acts as a reservoir of blood
immune globulin production
creation of clotting factors
mediates endocrine functions
metabolism of nutrients
excretion of bilirubin
metabolizes drugs
32
Q

What are some specific risk factors to ask about if liver disease is suspected?

A 
jaundice?
hx of blood transfusions?
drug or alcohol use?
current medications + herbals?
family history of liver disease?
travel history?
occupational history?
33
Q

What are some physical exam findings that might be common in liver disease?

A

easy bruising, anorexia, weight gain, weight loss, N/V, ascites, pruritis, GI bleeding

34
Q

When might the patient have an increased risk for intra-op morbidity and mortality?

A

based on high Child-Turcotte-Pugh scores and MELD scores.

These tests look at encephalopathy, ascites, bilirubin, albumin, PT/INR, primary biliary cirrhosis

35
Q

When would you want to order liver function tests?

A

in the case of significant liver disease, overt jaundice symptoms, weight changes >15%, severe drinking problem, prolonged or unusual bleeding, patient has an overt GI bleed, patient admitted to the hospital in the last year?

36
Q

What are some examples of liver function tests?

A 
AST/ALT
GGT
AP
serum albumin
serum bilirubin
prothrombin time
37
Q

What are some specific assessments that the CRNA could look at to assess the severity of liver disease?

A 
hand tremor (could represent encephalopathy)
dependent edema
hx of blood transfusions
presence of hepatitis
ascites or jaundice
38
Q

What general lab studies might be required in a patient with severe liver disease?

A 
CBC, BMP, clotting studies
albumin
glucose
liver enzymes
serum ammonia levels
blood alcohol level or a tox screen if acute use is suspected

ABG?

39
Q

How is a patient’s CV system affected if they have liver disease?

A 
increased levels of vasodilators 
higher cardiac output
decreased SVR
AV shunting
portal HTN

a pre-op EKG is warranted in severe liver disease

40
Q

What are the respiratory effects of liver disease?

A

ascites can decrease FRC and decrease diaphragmatic movement

shunting can cause V;Q mismatch

41
Q

How can liver disease impact intraop fluid status?

A

ascites and edema can cause wide swings in BP and general fluid status, so treat volume loss accordingly based on central filling pressures in severe cases

42
Q

What are some general CNS considerations for a patient with liver disease?

A

encephalopathy is common and so patient may have decreased LOC or altered mentation

43
Q

What are some common symptoms to assess for in a patient with GI or liver dysfunction?

A

nutritional changes, weight loss, N/V, blood in stool, GI bleed, abdominal pain or distention, abdominal mass, dysphagia, gastric acidity, reflux, jaundice, easy bruising, pruritis, ascites, hepatomegaly or splenomegaly, palmar erythema, gynecomastia, ecchymosis or spider angiomas

44
Q

What are some expected findings in cholestatic disease?

A

increased peripheral vasodilation
increased CO
increased portal venous pressure
decreased portal venous blood flow

45
Q

What is the main anesthetic consideration when taking care of a patient with cholestatic disease?

A

patient is at a predisposition for a Vitamin K deficiency, and long term disease can cause liver dysfunction resulting in abnormal protein synthesis

*should treat with exogenous Vit K and FFP if the patient starts bleeding

46
Q

In acute hepatitis, pre-operative evaluation should focus on…

A

S&S of encephalopathy, bleeding, jaundice, ascites, hemodynamic instability

47
Q

What might be some good lab results to review in a patient with hepatitis?

A

albumin, birlirubin, PT/INR, electrolytes, BUN/Cre, glucose, H&H, liver enzymes, ABG

48
Q

What are some risk factors for non-alcoholic fatty liver disease?

A

NIDDM and obesity

49
Q

What is the timeline for alcohol withdrawal?

A

6-8 hours – tremors
24 hours – hallucinations and grand mal seizures
72 hours – DTs

50
Q

What are the main anesthetic considerations when caring for a patient who is withdrawing from alcohol?

A

treat with benzodiazepines

prepare to leave the patient intubated and possible dispo to the ICU

51
Q

What are the hemodynamic changes in a patient with cirrhosis?

A

high CO
low PVR

*will probably need a cardiac clearance pre-op

52
Q

What are some S&S of cirrhosis?

A 
esophageal varices
intrapulmonary shunting
V/Q mismatch
arterial hypoxemia
ascites and edema
coagulation disorders
hormone disorders
encephalopathy
portal HTN
53
Q

How does liver disease affect the clotting cascade?

A

affects it at all 3 stages:

  1. hemostasis
  2. coagulation
  3. fibrinolysis
54
Q

What clotting factors are deficient in liver disease?

A

2, 5, 7, 9, 10

55
Q

How are platelets affected in liver disease? why?

A

altered function and decreased # of circulating platelets

*because they are derived from thrombopoetin, which is a protein normally synthesized in the liver

56
Q

What is the importance of Vit. K?

A

its a fat-soluble vitamin absorbed in the small intestine only in the presence of bile salts. it’s necessary for the production of Factors 2-7-9-10. deficiencies cause prolonged PT/PTT.

57
Q

When can a Vit. K deficiency develop?

A

patients on parenteral nutrition, biliary obstruction, pancreatic insufficiency, malabsorption, GI obstruction and rapid GI transit

Advanced Health Assessment (10 decks)

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