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Anesthesia Concepts 2 > Liver and GI > Flashcards

Liver and GI Flashcards

1
Q

NPO guidelines

A

In “healthy patients” liberal fasting guidelines can be followed
No chewing gum or candy after midnight
Clear liquids up to 2 hours before OR
Breast milk up to 4 hours before OR
Light meal, milk, formula up to 6 hours before OR
Sip of water or liquid pre-med up to 1 hour before OR

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2
Q

Who are aspiration risks?

A 
Age extremes 70 yr
Ascites (ESLD)
Collagen vascular disease, metabolic disorders (Diabetes obesity, ESRD, hypothryoid)
Hiatal Hernia/GERD/Esophageal surgery
Mechanical obstruction (pyloric stenosis, intestinal obstru)
Prematurity
Pregnancy
Neurologic diseases
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3
Q

Who is at greatest risk for aspiration and what is the treatment

A 
Pregnant
morbidly obese
hiatal hernia patients
Pre-operative anxiety 
Treatment includes
H2 receptor antagonists
Sodium Citrate (Bicitra)
Metoclopramide
Omeprazole
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4
Q

What are the H2 antagonists?

A

Cimetidine Zantac and Famotodine (best result)
Act as competitive antagonists of histamine binding to H2 receptors on gastric parietal cells
Reduces acid secretion
Best if given the night before and repeated 45-60 minutes before surgery

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5
Q

What is Metoclopramide and how does it work?

A

dopamine antagonists increases the pressure of the lower esophageal sphincter which speeds gastric emptying
Prevents or alleviates nausea and vomiting
Contraindicated in the presence of an obstruction

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6
Q

How dies Sodium Citrate work?

A

Non-particulate antacid
Customary dose of 30 mls to raise gastric ph
Increases gastric volume
Give 15 minutes before surgery and lasts 1-3 hours

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7
Q

What is Mendelson Syndrome and how does it manifest?

A 
Aspiration Pneuomitis
Characterized according to 
pH
Volume
Gastric material aspirated
Risk factors for aspiration sequelae include
Gastric volume of 0.4ml/kg (25ml/70kg)
pH less than 2.5 
Manifests as resp distress with bronchospasm cyanosis, tachycardia and dyspnea from irritating     action of hydrochloric acid and particulate material which are damaging to the lungs
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8
Q

What are the s/s of Barrett’s Esophagus and what is the treatment?

A 
H2 Blockers 
Proton Pump Inhibitors
Nissen fundoplication
Signs & Symptoms
Dysphagia
Reflux Esophagitis
Retrosternal pain or heartburn
LES dystonia
Weight loss
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9
Q

What is a Hiatal Hernia and s/s?

A

Protrusion of a portion of the stomach through the hiatus of the diaphragm upward into the thoracic cavity
Surgical repair may be recommended
Signs & Symptoms: Retro-sternal discomfort, Burning after meals

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10
Q

Who is at risk for PUD?

A 
Men and Women age 45-60
Chronic use of NSAIDS
ETOH
Steroids
Epigatric pain
Vomiting
Hematemesis or melena (this may be acute hemorrhage)
Abdominal tenderness and rigidity
Perforation
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11
Q

What is PUD and treatment?

A

Ulcerations in the GI mucosa
Most commonly the duodenal bulb or antrum of stomach
H. Pylori –Cause

Treatment: 
H2 antagonists
Proton pump inhibitors
Antimicrobial therapy
Antacids
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12
Q

S/S of Gastric Ulcers?

A

Pain
Anorexia
Weight loss
Metabolic derangements

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13
Q

What are Malabsorption Syndromes?

A 
Clinically significance deficits in mineral, vitamins and electrolytes
Small Bowel perforation or obstruction
Small Intestine
Celiac Sprue
Fat Malabsorption
Protein Malabsorption
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14
Q

What are your Malabsorption Syndromes s/s?

A 
Signs & Symptoms
Unexplained wt. loss
Steatorrhea
Diarrhea
Anemia
Fatigue
Deficiency in Vitamin K 
Bleeding dyscrasia
Edema/ascites
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15
Q

What is Chron’s Disease?

A

Distal ileum and large colon
Deficiency in magnesium, B12, Phosphorus, Folic acid, Zinc, Iron potassium,
Protein Loss decreased plasma albumin
Anemia

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16
Q

What is Ulcerative Colitis?

A 
Distal Colon and rectum
Intermittent bloody diarrhea
Fever/ malaise
 anorexia/wt. loss
Abdominal  pain
Associated with risk of colon cancer
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17
Q

What is Carcinoid Syndrome?

A

Site of origin is in the GI tract (appendix, pancreas or bronchi)
Most symptoms are produced by the effects of hormones and substances secreted in the GI tract and systemic circulation
Bradykinin
Histamine
Serotonin
Dopamine

18
Q

What are the S/S of Carcinoid Syndrome?

A 
Cutaneous flushing
Diarrhea
Palpitations
Bronchospasm
dyspnea
Hypotension
Hypertension
Orthostasis 
Pre-op test are guided by physical findings
19
Q

What are general preoperative considerations for the GI Patient?

A 
Airway management and prevention of aspiration
Fluid and Electrolyte Balance
Skin 
Peripheral circulation 
Heart rate 
Blood pressure
Urine output
Kidney function
Orthostasis
20
Q

Useful Labs and Monitoring?

A 
Useful Lab values:
Hematocrit
Serum electrolytes
BUN
Serum albumin
Monitoring :
Does patient need invasive lines
CVP or PAP monitoring
Aline
21
Q

What is malnutrition associated with?

A 
prolonged hospital stay 
Wound infection
Abscess
Respiratory failure
death
22
Q

What is the serum albumin level associated with?

A

Less than 3.5 in the general surgical population is accurate predictor of malnutrition
Less than 2.1 major predictor of morbidity in veterans undergoing non-cardiac surgery

23
Q

What are the physiologic function of the liver?

A 
Vital reservoir of blood represents 10-15% total blood volume
Maintains normal clotting 
Mediator of endocrine functions
Bilirubin excretion
Metabolism
Synthesis of proteins
Immunologic Function
Pharmacokinetics
24
Q

What are the risks factors and symptoms associated with chronic liver disease

A 
History of jaundice,
Prior blood transfusions
Recreational drugs/Alcohol 
Current medications includng herbals 
Family history of jaundice and liver disease 
Travel history 
Occupational history
ROS: easy bruising, anorexia, weight loss or gain  N&V, pain,   pruritus, GI bleeding
25
Q

How do you grade prep liver dysfunction?

A 
MELD Score
Child-Turcotte -Pugh Score
Encephalopathy
Ascites
Bilirubin
Albumin
PT (INR)
Primary biliary cirrhosis
26
Q

What are abs to assess liver function?

A 
AST and ALT
Alkaline phosphatase
5’Nucleotidase
GGT
Serum bilirubin
Prothrombin Time
Albumin (normal 3.5-5.0 g/dl)
Complete CBC
Coagulation studies
Serum electrolytes and glucose levels
Serum ammonia levels
Platelet count >100,000
Toxicology
27
Q

What CV things should you look for or expect?

A 
Increased levels of endogenous vasodilators such as vasoactive intestinal peptide
High cardiac output
Decreased systemic vascular resistance
Hyperdynamic circulatory state
Arteriovenous shunting
Portal hypertension
Pre-operative EKG is warranted
28
Q

What respiratory and fluid balance things should you look for?

A

Respiratory:
Ascites impairs the movement of the diaphragm resulting in decreased FRC
Right to left shunting secondary to arterivenous shunting
Fluid balance:
Ascites and edema offer evidence of derangement in fluid status
Correction of volume status with attention to central filling pressures

29
Q

What is this cholestatic disease?

A

Cholestatic disease predisposes towards Vitamin K deficiency
Biliary obstruction coagulopathy results from a deficiency of factors dependent on Vitamin K (II,VII, IX, X)
Absorption of Vitamin K depends on Bile Salt excretion into GI tract
Long term biliary obstruction can cause liver dysfunction interfering with protein synthesis

30
Q

What is the treatment of cholestatic disease?

A

Treatment is to correct with parental Vitamin K
FFP is necessary if emergent surgery or presence of hepatic injury
Expected findings
Increased peripheral vasodilation
Increased CO
Increased portal venous pressure
Decreased portal venous blood flow

31
Q

What should the preoperative assessment focus on with the patient with acute or chronic hepatitis?

A

Preoperative evaluation should focus on signs and symptoms of encephalopathy, bleeding, jaundice ascites, and hemodynamics)
Lab findings
Electrolytes, BUN, creatinine, serum glucose, H/H, liver enzymes, bilirubin, coagulation studies, and abg

32
Q

What is non-alchoholic fatty liver disease?

A

Most common cause of chronic liver disease
Fat accumulation in the liver exceeding 5%
Risk factors include NIDDM and obesity
Asymptomatic but elevated liver enzymes (AST & ALT) found on physical exam
Produces some degree of hepatocyte necrosis which promotes the accumulation of inflammatory cells in liver
Leads to cirrhosis
Weight loss (even 5 lbs) can reverse the elevated liver enzymes

33
Q

Alcoholic liver disease s/s

A 
malaise 
nausea 
anorexia 
Weakness
 abdominal discomfort
hepatomegaly jaundice

Results in:
Steatosis (fatty liver)
Alcoholic hepatitis (precursor Cirrhosis)
Cirrhosis

34
Q

What are characteristics of DTs

A

Within 6-8 hours of ETOH withdrawal patient may become tremulous
Alcohol hallucinosis and grand mal seizures occur within 24 hours
DTs usually appear within 72 hours of withdrawal and are preceded by tremulousness, hallucinations or seizures
Treatment is with benzodiazepines

35
Q

What are s/s of cirrhosis?

A 
Anorexia weakness nausea vomitting abd pain hepatomegaly ascites jaundice spider nevi metabolic encephalopathy
Hyperdynamic circulation
high CO
low PVR 
Gastroesophageal variceal
Intrapulmonary shunting 
Ventilation Perfusion mismatch
Arterial hypoxemia due to Intra-pulmonary vascular dilations (IPVD)
Ascites and Edema
Coagulation disorders
Endocrine disorders
Hepatic encephalopathy
Portal Hypertension
36
Q

What are the three abnormalities you have related ti clotting and platelet function?

A

Hemostasis
Coagulation
Fibrinolysis

37
Q

What are the coagulation disorders?

A

Disorders of coagulation rapidly develop in patients with severe liver failure
Factors II, V, VII, IX, X all reduced in liver failure
PT and INR elevated
Thrombocytopenia
Abnormal fibrinogen

38
Q

What are platelet disorders?

A

Abnormal platelet function
Decreased platelet function
Increased bleeding time

39
Q

What are disorders of clotting factors?

A

Vitamin K deficiency
Coumadin Therapy
Heparin Therapy

40
Q

Vitamin K helps make what factors?

A

Vitamin K is necessary for the hepatic synthesis of Factors II, VII, IX, X, and Protein S and Protein C

41
Q

Vitamin K deficiency develops in what type of patients?

A

Vitamin K deficiency develops in patients on parenteral nutrition, biliary obstruction, pancreatic insuff, malabsorption, GI obstruction and rapid GI transit
Effects of Vitamin K deficiency include prolonged PT, PTT

Anesthesia Concepts 2 (10 decks)

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