GI, GU, Integumentary.docx

- **NPO guidelines for elective surgery in otherwise healthy patients** - Clear liquids for up to 2 hours before induction - Breast milk up to 4 hours before induction - Infant formula/non-human milk, light meal 6 hours before induction - Heavy solids, fatty...

- **NPO guidelines for elective surgery in otherwise healthy patients** - Clear liquids for up to 2 hours before induction - Breast milk up to 4 hours before induction - Infant formula/non-human milk, light meal 6 hours before induction - Heavy solids, fatty foods, meat 8 hours before induction - GLP1 Agonists - Physiologically -- lower blood sugar, increase the sense of satiety (i.e. fullness), delayed gastric emptying (i.e. full stomach) - Recommendation is to be off drug for 1xweek for parental - Recommendation is to be off drug for 1x day for daily (enteral) dose - Alpha gal syndrome - Lone star tick bite causes hypersensitivity to animal proteins - Non-contagious - Allergic reaction type symptoms can be immediate or delayed - Medications that pose a risk = heparins, gelatin capsules, vaccines, lidocaine patches - Unsafe = propofol, hydromorphone, acetaminophen, clevidipine, milrinone, all antiplatelets except rectal aspirin - Who has a full stomach/delayed gastric emptying? - Diabetic patients due to gastroparesis - Pregnant women in labor - Trauma patients - Pts that have been treated with opioids -- decreased gastric motility - All of these patients should have RSI - Put monitors on and denitrogenation/pre-oxygenation - Give induction, NMB, and intubate - Ventilate after intubation - Routine testing should not be performed unless there are specific disease/comorbidities/risks to anesthesia - Goal of preoperative evaluation includes - Discovery of diseases/disorders - Verification or assessment of known disease influencing anesthesia care - Support the formulation of a specific care plan - Health history for GI Assessment - Nausea and vomiting lead to metabolic alkalosis due to loss of gastric acid - Diarrhea leads to metabolic acidosis due to loss of bicarbonate - Esophageal disease - **Dysphagia** = difficulty swallowing - **Structural** -- common with solid food - **Functional**/**motility** -- common with liquids and solid food - Heartburn common with GERD - Acid in distal esophagus causing a feeling of discomfort - Regurgitation = reflux of GI contents into the pharynx without nausea/vomiting - Odynophagia = pain with swallowing - Globus sensation = feeling of a lump in the throat - **Esophagogastroduodenoscopy** \[EGD\] is the best method for evaluation of mechanical causes of dysphagia - **Most esophageal disorders represent an aspiration risk** - Esophageal disorders relating to motility - **Achalasia** = outflow obstruction caused by poor relaxation of the lower esophageal sphincter and hypomotile esophagus - **Distal esophageal spasm** = spastic distal portion of the esophagus - Esophageal disorders relating to structure - Diverticula - Hiatal hernia - Tumors - **GERD =** gastric contents re-enter the esophagus due to - transient relaxation of the lower esophageal sphincter (LES) - poor LES tone - anatomic distortion of the GE junction (e.g. hiatal hernia) M - **Peptic ulcer disease** - **H. Pylori** is the offending agent, causing an increase in gastric acid secretion - Sx = epigastric pain relieved by eating and worsened by fasting - Common disease affecting men slightly more than women - Complications include - Bleeding -- common without treatment and can cause mortality - Perforation - Obstruction -- edema and inflammation may lead to an outlet obstruction - Esophageal varices - Dilations and weakening in the wall of the esophagus - Due to cirrhosis and scar tissue/ portal hypertension - Treatment to fire band around varicosity so it scars over - Esophageal gastrectomy -- can be used to treat esophageal cancer. 33% mortality - **Carcinoid tumors** - Occur most commonly in GI tract - Known to secrete vasoactive substances (ACTH, serotonin precursor, growth hormone factor) - Types of secretory substances tend to vary depending on location of tumor - Carcinoid syndrome occurs in approximately 10% of patients - Serotonin is normally secreted in GI tract when we eat and excreted by lungs. Carcinoid tumors cause increase in serotonin due to secretion by tumor - **Carcinoid syndrome**: occurs due to secretion of large amounts of serotonin and vasoactive substances reaching the systemic circulation - Sx = flushing secondary to histamine release, diarrhea secondary to excess serotonin, dehydration and electrolyte abnormalities - Carcinoid crisis is life threatening and characterized by flushing, diarrhea, abdominal pain, tachycardia, hypertension/hypotension - Drugs provoking mediator release = Succs, mivacurium, atracurium, tubocurarine, epi, NE, dopamine, isoproterenol, thiopental - **Pancreatitis** - Pancrease manufactures and secrete numerous digestive enzymes (i.e. proteases) - Gallstones and alcohol abuse are the etiologic antecedents of pancreatitis in 60-80% of cases - Gallstones obstruct bile ducts causing pancreatitis - Hypercalcemia, pancreatic ductal hypertension lead to the intrapancreatic release of digestive enzymes and acute inflammatory changes - Sx = excruciating pain, N/V, ileus, dyspnea - Complications = shock, ARDS, renal failure, GI hemorrhage, coagulopathy and DIC - shock occurs secondary to hypovolemia, vasodilation, and release of pancreatic enzymes into the general circulation - major risk factor for death - hypotension occurs due to sequestration of fluid in the peripancreatic space which leads to hemorrhage/systemic vasodilation - ARDS occurs in 20% of patients - Infection of pancreatic necrotic material or abscess formation is associated with \>50% mortality - GI bleeding - Upper GI bleeding is more common than lower. Upper GI bleed is usually caused by PUD - Tachycardia and hypotension are common when EBL \>25% of EBV - Lower GI bleed is usually from diverticulosis or tumors - Melena suggests bleeding has occurred above the cecum - Orthostatic hypotension typically occurs when Hct \1.018 suggests urine concentrating ability is adequate - Urinalysis detects the presence of proteins, glucose, acetoacetate, blood, and leukocytes - Hematuria may be the result of bleeding anywhere between the glomerulus and urethra - AKI = increase in serum Cr \>0.3 mg/dl within 48 hours or \>50% over 7 days OR decrease in urine output to \ 50% - Causes include sepsis, cardiovascular dysfunction, pulmonary complications - Pre-renal, intra-renal, and post-renal causes - Risk factors = pre-existing renal disease, CV disease relying on intraoperative inotropes, aortic cross clamping, respiratory disease, post op reliance on inotropes, post op diuretic use, sepsis, nephrotoxic drug admin - Complications = Asterixis, polyneuropathy, uremic pericarditis, hyperkalemia, metabolic acidosis - Pre-renal (blood supply to kidney), intrarenal (issue with kidney), postrenal (obstruction) - CKD = GFR \