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GI/Liver Flashcards

1
Q

Upper GI Endoscopy =

A

Esophagogastroduodenoscopy (EGD)

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2
Q

EGD: Purpose

A

Diagnostic/therapeutic

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3
Q

EGD: most common position

A

Left lateral decubitus most common

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4
Q

Porphyria Safe or Unsafe Drug:

Phenacetin

A

UNsafe

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5
Q

What is an EGD

A

Flexible scope into esophagus to small intestine

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6
Q

T/F: We always use sedation/anesthesia for EGD procedures

A

False.

+/- sedation/anesthesia

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7
Q

EGD: Share the airway

A
  • Natural airway- avoid apnea, jaw lift, O2 nasal cannula
  • Vs. GA w/ ETT
  • Cardiopulmonary complications most common
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8
Q

EGD: When is the bite block placed?

A

Bite block placed:

Prior to sedation

OR

if GA, after ETT placement

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9
Q

Porphyria Safe or Unsafe Drug:

Locals

A

Safe

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10
Q

What is achalasia?

A
  • Neuromuscular disorder of esophagus
  • Symptoms typically include:
    • dysphagia
    • regurgitation
    • heartburn
    • chest pain
  • Unopposed cholinergic stimulation of LES → failed relaxation → HTN of LES → reduced peristalsis → esophageal dilation → food stasis in esophagus
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11
Q

Treatment for achalasia

A
  • Palliative
    • Botulinum injection
    • Dilation
    • Per Oral Endoscopic Myotomy (POEM)
      • Endoscopically dividing circular muscle layer of LES
      • Requires CO2 insufflation of esophagus → requires mech vent
      • High pain and N/V → plan?
        • aggressive: zofran, scopolamine, haldol, phenergan, fluids
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12
Q

Anesthesia plan for achalasia

A
  • R/f aspiration = RSI with ETT, awake extubation
  • If they feel like they have food stuck = place NGT prior to induction and suction out
  • If not so bad, maybe not as agressive
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13
Q

Porphyria Safe or Unsafe Drug:

Calcium Channel Blockers

A

UNsafe

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14
Q

Zenker’s diverticulum

A
  • Pharyngoesophageal outpouching
    • RSI
    • Avoid cricoid pressure if sac is immediately behind cricoid cartilage
    • GA induced w/ head-up position
    • Avoid NGT/OGT (could go into pouch and rupture it)
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15
Q

Hiatal hernia

A
  • Herniation of stomach into thoracic cavity
    • May be asymptomatic
    • +/- RSI w/ cricoid, ETT
    • OGT
    • Awake extubation
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16
Q

GERD

A
  • Preop pharmacological treatment
    • Cimetidine, ranitidine, famotidine
    • PPIs
    • Sodium citrate
  • Aspiration risk
    • Aspiration pneumonitis
    • RSI w/ cricoid… OG/NGT…Awake extubate
    • Sch ↑LES pressure and intragastric pressure, but barrier pressure unchanged (so no increased risk)
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17
Q

What is aspiration pneumonitis?

A

Aspiration pneumonitis =

volume 0.4-0.5 mL/kg of gastric contents & PH < 2.5.

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18
Q

Peptic Ulcer Disease

A
  • Burning epigastric pain exacerbated by fasting & improves w/ eating
  • Complications include: bleeding, perforation, obstruction
  • May be on chronic antacids (electrolyte imbalances)
    • H2 receptor antagonists → cimetidine and ranitidine inhibit P-450 → monitor warfarin, phenytoin, theophylline levels if pt on these
    • PPIs → impair P-450
  • NG/OG placement
  • RSI consideration
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19
Q

Porphyria Safe or Unsafe Drug:

Inhalational agents

A

Safe

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20
Q

Upper GI bleeding

A
  • Hypotension, tachycardia if blood loss is >25% of TBV
  • Orthostatic hypotension = hct < 30%
    • Hct may be normal early in acute hemorrhage
  • Elevated BUN
  • Fluid status
  • Esophageal variceal bleeding? Give Octreotide
  • EGD for eval and treatment
    • Aspiration risk… GA/ ETT
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21
Q

Lower GI bleeding

A

Colonoscopy after bowel prep for evaluation

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22
Q

Crohn’s Disease

A
  • Inflammation of all layers of the bowel
  • May lead to fistula development
  • Fear of eating, anorexia, diarrhea, pain
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23
Q

Ulcerative Colitis

A
  • Inflammation of colonic mucosa → rectum and distal colon (lower bowel)
  • Fever, N/V/D, cramping, abd pain, anorexia, weight loss
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24
Q

Anesthetic considerations for IBD

(Crohn’s and Ulcerative Colitis)

A
  • Fluid and electrolyte management
  • Avoid N2O
  • Supplemental steroids as required
  • Anticholinesterases ↑ intraluminal pressure (not a contraindication, just something to be aware of)
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25
Q

Colonoscopy

A
  • Diagnostic and/or therapeutic
  • Typically left lateral decubitus
  • +/- sedation/anesthesia
  • May be combined w/ EGD
  • If completed in isolation- generally natural airway
  • Bowel prep and dehydration is major concern
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26
Q

Acute Pancreatitis

A
  • Acute inflammatory disorder
  • Excruciating, unrelenting mid-epigastric pain relieved by leaning forward
  • N/V
  • Abdominal distention and ileus possible
  • Fever, tachycardia, hypotension and shock possible
  • ↑ in serum amylase and lipase concentration
  • ERCP
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27
Q

Porphyria Safe or Unsafe Drug:

Insulin

A

Safe

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28
Q

Porphyria Safe or Unsafe Drug:

NDMR

A

Safe

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29
Q

Chronic Pancreatitis

A
  • Most often d/t chronic alcohol abuse
  • Epigastric pain radiates to back, frequently postprandial
  • DM d/t end result of loss of endocrine function
  • Thin or emaciated
  • Serum amylase levels typically normal
  • ERCP
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30
Q

Considerations for Pancreatitis

A
  • DM management
  • Aggressive fluid administration even for mild cases
  • Colloid replacement
  • Pain control
  • NGT/OGT prior to induction
  • RSI +/-
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31
Q

What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)

A
  • ERCP used to diagnose and treat conditions of bile ducts: gallstones, inflammatory strictures, leaks (from trauma and surgery), and CA.
  • ERCP combines use of x-rays and an endoscope.
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32
Q

ERCP Anesthesia Considerations

A
  • Duration: 30 min-2 hrs (TIVA vs GA)
  • Aspiration concerns: GA w/ ETT, RSI w/ awake extubation
  • Bite block
  • Usually supine, maybe L lateral
  • Consider glucagon, NTG or naloxone and actions of opioids on Sphincter of Oddi
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33
Q

What are carcinoid tumors?

A
  • Originate in GI tract most of time
  • Secrete corticotropic hormones, GI peptides, prostaglandins and bioactive amines (serotonin)
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34
Q

Carcinoid syndrome

A
  • Systemic release of serotonin and vasoactive substances
    • Flushing and diarrhea
    • Dehydration and electrolyte disturbances
    • Hypotension, HTN
    • Bronchoconstriction
    • Occasional R side heart manifestations
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35
Q

Carcinoid syndrome is usually precipitated by…

A

Precipitated by:

  • stress
  • exercise
  • alcohol
  • catecholamines
  • serotonin reuptake inhibitors
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36
Q

What is carcinoid crisis?

A
  • Potentially life threatening
  • Intense flushing, diarrhea, abd pain, tachycardia, hypo or hypertension
  • Spontaneous or provoked by:
    • Stress
    • Chemotherapy or tumor biopsy
    • Certain drugs
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37
Q

Carcinoid tumor treatment

A
  • Somatostatin analogue octreotide
  • Resection of tumor by surgery
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38
Q

Carcinoid Tumor Anesthetic Management

A
  • Give Octreotide 24-48 hrs b4 surgery; continue throughout procedure
  • Prevent crisis→ premed for stress control
  • Avoid drugs that provoke mediator release
  • ​Treat bronchospasm w/ octreotide and histamine blockers, +/- ipratropium
    • (avoid B-agonists → will exacerbate d/t mediator release)
  • Invasive monitors- A-line
  • Ondansetron great choice (serotonin antagonist)
  • Potential ICU care post-op d/t delayed emergence
  • Epidural analgesia OK if octreotide treatment has been adequate
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39
Q

Drugs that provoke mediator release (carcinoid tumor)

A
  • succinylcholine
  • mivacurium, atracurium, tubocurarine
  • epi, norepi, dopamine, isoproterenol
  • thiopental
  • b-agonists
  • histamine releasers
  • ketamine
40
Q

Porphyria Safe or Unsafe Drug:

Opioids

41
Q

Anesthesia for Bowel Obstruction

A
  • No metoclopramide - Avoid agent that increases gastric motility
    • Others? (neostigmine)
  • No N2O
  • RSI: Treat as full stomach
  • Albumin + Volume replacement
  • Electrolyte status
  • Place OGT
42
Q

Acute Cholecystitis

A
  • Gallbladder or biliary tract stone
  • Women, fair skinned, obesity, increased age = “Fair/Fat/Forty/Female” ,rapid weight loss, pregnancy
  • Fever, N/V, abdpain, RUQ tenderness radiates to back, intense pain, dark urine, scleral icterus (bile duct stones)
    • Asymptomatic (gallbladder stones)
  • Surgery when condition stable
    • Laparoscopic → 5% convert to open
    • ERCP
43
Q

Laparoscopic Procedures

A
  • Insufflation of abd cavity (pneumoperitoneum) → ↑ intra-abd pressure leads to…
    1. Inadequate ventilation
    2. ↓venous return → ↓CO and ↑MAP and SVR
    3. Bradycardia d/t peritoneal stretching
  • ↑ MAP and SVR over several min restores CO
    • d/t ↑ abd pressure, neurohumoral response and absorbed CO2
  • Risk for:
    • vascular injury
    • acute blood loss
    • CO2 embolism
  • Considerations for conversion to open
    • fluids, pain
44
Q

Porphyria Safe or Unsafe Drug:

Etomidate

45
Q

Considerations for Laparoscopic Procedures

A
  • Pre-Induction/Induction
    • Consider volume and electrolyte replacement
    • Preop abx
    • RSI w/ cricoid pressure/cuffed ETT
  • Watch PIP/MV and adjust ventilation accordingly
  • Reverse Trendelenburg aids surgical access & may improve ventilation
  • Support BP & HR
  • NG/OGT
  • Avoid N2O
  • Judicious use of opioids
    • Opioids may cause Sphincter of Oddi spasm (morphine)
      • <3% incidence
      • Antagonize spasm with IV Glucagon/Naloxone/NTG
46
Q

Hepatitis

A
  • Inflammation of liver parenchyma
    1. Viral
    2. Non-alcoholic fatty liver dz
    3. Alcoholic liver dz
    4. Inborn errors of metabolism
    5. Autoimmune
    6. Drug-Induced
    7. Cardiac causes
  • Symptoms may be minimal (malaise/jaundice) to severe w/ compromise to multiple organ systems
47
Q

Acute vs Chronic Hepatitis

A
  • Acute → usually self-limiting, rapid development of liver damage and impaired function, high mortality rate
  • Chronic → Hepatic inflammation > 6 months → Cirrhosis, hepatocellular carcinoma or liver failure
48
Q

What is cirrhosis

A

Chronic, progressive parenchymal damage leads to scarring and nodular formation

49
Q

S&S of cirrhosis

A
  1. Anorexia/weakness/N/V
  2. Ascites/hepatomegaly (Ascites = RSI)
  3. Fatigue/Malaise (careful w/ sedation)
  4. Jaundice
  5. Spider angiomata
  6. Hypoalbuminemia (protein binding drugs; give albumin)
  7. Portal HTN
  8. Coagulation dx
  9. Endocrine dx
  10. Gastroesophageal varices
  11. Hyperdynamic circulation
  12. Hepatic encephalopathy (MAC requirements decreased)
  13. Hepatorenal & Hepatopulmonary syndrome
50
Q

Porphyria Safe or Unsafe Drug:

PCN

51
Q

Cirrhosis: Labs

A
  • Elevated:
    • Bilirubin
    • Aminotransferase
    • Alkaline phosphatase
    • INR
  • Decreased:
    • Serum albumin
    • Platelets
    • Blood sugar
52
Q

Cirrhosis: Child-Pugh Score

A
  • Severe liver dz = diminished ability to respond to stress
  • Main 2 determinants of peri-op risk = extent of liver damage and type of surgery
  • Used specifically to predict surgical mortality w/ cirrhosis
    • Class A = 10% mortality rate in intraabdominal surgery
    • Class B = 30% mortality
    • Class C = 80% mortality
    • A/B w/ preop optimization OK for surgery; class C surgery should be delayed.
53
Q

What labs/assessments does Child-Pugh score look at?

A

Total bilirubin

serum albumin level

INR

ascites

hepatic encephalopathy

54
Q

Cirrhosis Anesthetic Considerations:

Preop Optimization

A
  • Preop Optimization!
    1. Improve diet w/ protein & caloric intake
    2. BG control pre/intra/post op (infusions w/ glucose?)
    3. Aldosterone antagonist
    4. Electrolyte and fluid status!
    5. Monitors?
55
Q

List the anesthetic considerations for cirrhosis

A
  1. Preop Optimization
  2. Encephalopathy
  3. Ascites
  4. Esophageal Varices
  5. Renal Impairment
  6. Hyperdynamic Circulation
  7. Coagulopathy
  8. Pharmacokinetics
  9. Liver blood flow
56
Q

Porphyria Safe or Unsafe Drug:

Amiodarone

57
Q

Cirrhosis: Anesthetic Considerations

Encephalopathy

A
  • RSI
  • Judicious use of sedatives and induction agents
58
Q

Cirrhosis: Anesthetic Considerations

Ascites

A
  • RSI
  • Mechanical ventilation
  • PFTs
  • PA pressures
  • Fluid status: For every 1 L of ascites removed, need 8g of albumin given
59
Q

Porphyria Safe or Unsafe Drug:

Most CV drugs

60
Q

Cirrhosis: Anesthetic Considerations

Esophageal Varices

A
  • No esophageal temp probe or NG/OGT
  • Bleeding? → RSI
    • Octreotide (50 mcg/hr) or
    • Vasopressin (20 U over 5 min)
61
Q

Cirrhosis: Anesthetic Considerations

Renal Impairment

A
  • Euvolemia
  • Monitor and correct for acid-base and electrolyte imbalances
  • Refer to renal lecture for renal considerations
62
Q

Cirrhosis: Anesthetic Considerations

Hyperdynamic Circulation

A
  • ↓ SVR mostly compensated w/ ↑CO
  • Hypoalbuminemia → edema
  • Cardiomyopathy
    • Avoid myocardial depressants
  • Invasive monitors, intravascular fluid replacement and vasopressors (phenylephrine/NE/Vasopressin)
  • Impaired response to catecholamines
    • Will see limited response to increased dose requirements
63
Q

Cirrhosis: Anesthetic Considerations

Coagulopathy

A
  • T/C
  • Vitamin K non-emergently
  • FFP, Cryo, platelets
    • Only factors NOT produced by liver are factors 3, 4, 12
  • PRBCs
    • Impaired ability to handle citrate loads
      • Ionized Ca++ monitoring and Ca++ admin
64
Q

Cirrhosis: Anesthetic Considerations

Pharmacokinetics

A
  • Albumin
    • ↓ protein binding and ↑VD
  • Decreased clearance
    • Ex: larger initial dose of NDMR to compromise for ↑ VD but ↓ subsequent dosing d/t ↓ clearance
  • Propofol or etomidate great options- consider smaller induction doses
  • Succinylcholine and cisatracurium (good options) = no hepatic metabolism
  • Caution w/ drugs dependent on liver clearance and drugs toxic to liver.
    • ​cisatra/atra/miv great options
65
Q

Porphyria Safe or Unsafe Drug:

Propofol

66
Q

Cirrhosis: Anesthetic Considerations

Maintain Liver Blood Flow

A
  • Hepatic artery 25% blood flow w/ 50% oxygen delivery
  • Portal vein 75% blood flow w/ 50% oxygen delivery
  • IV anesthetics maintain hepatic blood flow if arterial blood pressure maintained
  • All inhalational agents maintain hepatic blood flow except halothane
  • Avoid SNS stimulation
67
Q

Porphyria Safe or Unsafe Drug:

Ketorolac

68
Q

Post-Op: Cirrhosis

A
  • Post-op morbidity is ↑
    • Liver dysfunction/failure (#1)
    • Renal failure
    • Bleeding
    • DTs
    • Electrolyte disturbances
    • Pneumonia
    • Sepsis
    • Poor wound healing
69
Q

Porphyria Safe or Unsafe Drug:

Nifedipine

70
Q

Alcoholism

A
  • Chronic ETOH causes enzyme induction = ↑anesthetic needs
  • Acute ETOH ↓anesthetic needs d/t ADDITIVE effects
  • Acute intoxicated→ RSI
  • Heavy ETOH can lead to acute hepatitis
71
Q

Porphyria Safe or Unsafe Drug:

Barbiturates

72
Q

Alcohol Withdrawal Syndrome:

S&S

A
  1. ↑SNS- catecholamine release
  2. Agitation
  3. Tachycardia
  4. Dysrhythmias
  5. Hemodynamic instability
  6. Diaphoresis
  7. DT’s (48-72 hrs post ETOH)→ medical emergency
  8. Hallucinations
  9. Grand mal seizures and hypoglycemia
73
Q

Alcohol Withdrawal Syndrome:

Treatment

A
  • Benzos
  • Beta antagonist (propranolol or esmolol)
  • Airway protection
  • Correct fluid/electrolyte and metabolic disturbances
  • DT’s mortality rate is 10% d/t hemodynamic instability, cardiac dysrhythmias and seizures
74
Q

Porphyria

A
  • Metabolic disorder resulting from deficiency of specific enzyme in heme biosynthetic pathway
  • Any increase in heme requirements results in accumulation of pathway intermediates (intermediates are toxic!)
  • Any metabolism needs that rely on CYP-450 isoenzymes induce ALA synthetase resulting in ↑ intermediates
  • Results in overproduction of porphyrins
    • Accumulation of intermediate forms of porphyrin at site of enzyme blocked
75
Q

What are porphyrins?

A
  • Porphyrins are essential for physiologic functions
    • O2 transport and storage
    • Heme most important porphyrin
      • Bound to proteins
    • Production regulated by aminolevulinic acid (ALA) synthetase
      • Controlled by endogenous concentration of heme
76
Q

Acute Intermittent Porphyria

A
  • Most serious
  • Attacks life threatening
  • Affects central and peripheral nervous system
  • Systemic HTN and renal dysfunction
77
Q

Porphyria: Triggers

A
  • Triggers
    • Enzyme inducing drugs
      • Allyl group on barbiturates
      • Steroid structure
      • Avoid pentathol, thiamylal, methohexital, etomidate
    • Hormonal fluctuations
      • Menstruation/menopause/pregnancy
      • Fasting (pre-op!)
      • Dehydration
      • Stress
      • Infection
78
Q

Porphyria: S&S

A
  1. Severe abd pain/N/V d/t autonomic neuropathy
  2. ANS instability
  3. CV instability resulting in HTN and tachycardia (less likely hypotension)
  4. Electrolyte imbalances (Na, K, Mg)
  5. Skeletal muscle weakness– respiratory failure
  6. Seizures
79
Q

Porphyria: Treatment

A
  1. Remove triggering agents
    • Multiple enzyme inducing agents more dangerous than exposure to any one drug
  2. Treat pain/N/V
  3. Fluid and electrolyte balance
    • 10% glucose saline infusion
  4. Hydration + Carbs
  5. BB for HTN and tachycardia
  6. Benzos for seizures
  7. Hematin 3-4 mg/kg IV; Somatostatin; plasmapheresis
80
Q

Porphyria Safe or Unsafe Drug:

Diazepam

81
Q

Anesthetic Management of Porphyria

A
  • Pre-op prep: Identify and avoid triggers (www.drugs-porphyria.com)
  • Minimize multiple drug exposure
  • Preop meds: Anxiolytics, aspiration prophylaxis
    • Cimetidine inhibits ALA synthetase activity and decreases heme consumption
  • Asses skeletal and CN function
  • Cardiac: HTN, tachycardia
  • Anticipate post-op ventilation
  • Minimize stress of preop fasting glucose-saline infusion
  • Fluid/electrolyte management
82
Q

Porphyria Safe or Unsafe Drug:

ASA/APAP

83
Q

Porphyria Safe or Unsafe Drug:

Glucocorticoids

84
Q

Porphyria: Regional

A

Regional

  • No absolute contraindications
  • Avoid in acute exacerbation
  • Pre-anesthetic neuro eval
  • ANS blockade may lead to CV instability especially w/ hypovolemia
85
Q

Porphyria Safe or Unsafe Drug:

Sulfonamide antibiotics

86
Q

Porphyria Safe or Unsafe Drug:

ETOH

87
Q

Porphyria Safe or Unsafe Drug:

Atropine/Glycopyrrolate

88
Q

Porphyria: General

A

General

  • Use short acting agents
  • Induction w/ propofol
  • Maintenance w/ N2O, inhaled anesthetics, opioids and NDMR
  • Monitors!
  • Cardiopulmonary bypass is a stressor
89
Q

Porphyria:

SAFE Drugs

A

Safe

  1. ASA/APAP
  2. Atropine/Glycopyrrolate
  3. Benzodiazepines
  4. Most CV drugs
  5. Glucocorticoids
  6. Inhalational agents
  7. Insulin
  8. Locals
  9. NDMR
  10. Neostigmine
  11. Opioids
  12. Propofol
  13. PCN
90
Q

Porphyria:

UNsafe Drugs

A

Unsafe

  1. Amiodarone
  2. Barbiturates
  3. Calcium channel blockers*
  4. Diazepam
  5. ETOH
  6. Etomidate
  7. Ketamine
  8. Ketorolac
  9. Nifedipine
  10. Phenacetin
  11. Sulfonamide abx
91
Q

Porphyria Safe or Unsafe Drug:

Neostigmine

92
Q

Porphyria Safe or Unsafe Drug:

Ketamine

93
Q

Porphyria Safe or Unsafe Drug:

Benzodiazepines

94
Q

What are the most common cardiopulmonary complications from EGD?

A
  • Desats
  • Airway obstruction
  • Laryngospasms
  • Aspiration
95
Q

S&S CO2 embolism (lap procedure)

A
  • Similar to VAE
    • Drop in etCO2
    • Hypotension
    • Tachycardia
    • Arrythmias
    • Wind mill murmur

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