Exam 2: GI and Liver

Question 1

Pre-op restriction on clear liquids:

Answer 1

2 hours

Question 2

Pre-op restriction on breast milk:

Answer 2

4 hours

Question 3

Pre-op restriction on light meals, milk, or formula:

Answer 3

6 hours

Question 4

Pre-op restriction on heavy meals:

Answer 4

8 hours

Question 5

Pre-op restriction on sips of water for meds:

Answer 5

1 hour

Question 6

Patients who are aspiration risks (8):

Answer 6

Age extremes ( 70)
Ascites
Hiatal hernia/GERD/esophageal surgery
Mechanical obstruction
Metabolic disorders
Neurologic diseases
Pregnancy
Prematurity

AAHMMNPP

Question 7

Four greatest risks for aspiration:

Answer 7

Pregnant
Morbidly obese
Hiatal hernia
Preoperative anxiety

Question 8

Aspiration prophylaxis:

Answer 8

H2 receptor antagonists
Sodium citrate/Bicitra
Metoclopramide/Reglan
PPI (i.e. omeprazole)

Question 9

Use of H2 blockers pre-op:

Answer 9

Best given night before & 45-60 minutes pre-op
Famotidine: best result
Also cimetidine, ranitidine

Question 10

Indications, MoA, and contraindications for pre-op metoclopramide:

Answer 10

Dopamine antagonism ↑ pressure on LES which speeds gastric emptying
Prevents/alleviates N/V
CONTRAINDICATED in obstruction!!

Question 11

MoA, dose, and timing of sodium citrate pre-op:

Answer 11

30mL, 15 minutes before surgery to raise gastric pH (also raises volume, though)

Question 12

Mendelson Syndrome characterized by:

Answer 12

Aspiration of > 25ml of gastric material at

Question 13

Manifestations of Mendelson Syndrome:

Answer 13

Respiratory distress
Bronchospasm
Cyanosis
Tachycardia
Dyspnea

Question 14

Tx for Barrett’s esophagus:

Answer 14

H2 blockers and PPIs

Nissen fundoplication

Question 15

S/s of hiatal hernia:

Answer 15

Retrosternal discomfort
Burning after meals
+/- reflux

Question 16

Tx of hiatal hernia:

Answer 16

Surgery

Question 17

Risk factors for PUD:

Answer 17

H. pylori
Age 45-60
Chronic NSAIDs
ETOH
Steroids

Question 18

S/s of PUD:

Answer 18

Epigastric pain
Vomiting
Hematemesis/melena
Abdominal tender/rigid
Perforation

Question 19

Tx of PUD:

Answer 19

H2 blockers and PPIs
Abx
Antacids

Question 20

Tx of PUD:

Answer 20

H2 blockers and PPIs
Abx
Antacids

Question 21

S/s of gastric ulcers:

Answer 21

Pain
Anorexia
Weight loss
Metabolic derangements

Question 22

Important pre-op considerations for malabsorption syndromes:

Answer 22

Fluids and electrolytes

Vitamin K levels!

Question 23

Important pre-op considerations for malabsorption syndromes:

Answer 23

Fluids and electrolytes

Vitamin K levels!

Question 24

S/s of malabsorptions syndromes:

Answer 24

Weight loss
Steatorrhea
Diarrhea
Anemia
Fatigue
Vitamin deficiency
Dyscrasias
Edema/ascites

Question 25

Lab abnormalities in Crohn's disease:

Answer 25

Deficiencies in magnesium, B12, phosphorus, folic acid, zinc, iron, postassium, albumin Anemia

Question 26

Carcinoid syndrome is:

Answer 26

Mild, non-metastatic cancer originating in the GI tract

Question 27

Substances secreted by carcinoid cancers:

Answer 27

Bradykinin Histamine Serotonin Dopamine

Question 28

Skin signs of GI problems:

Answer 28

``` Jaundice Small veins Cracked lips Turgor (mostly fluid-related) ```

Question 29

Useful GI labs:

Answer 29

Hgb/hct (fluid status) Electrolytes BUN/Cr Serum albumin

Question 30

Serum albumin range:

Answer 30

Should be > 4

Question 31

Liver's blood reservoir %:

Answer 31

10-15%

Question 32

Risk factors for chronic liver disease:

Answer 32

``` Blood transfusions Jaundice Drugs/ETOH Meds/fish oil Travel hx Occupational hx ```

Question 33

S/s of liver disease:

Answer 33

``` Bruising Anorexia Weight changes N/V Pain Itching GI bleeding ```

Question 34

Two grading scales for liver dysfunction:

Answer 34

MELD | Child-Turcotte-Pugh

Question 35

Factors in the Child-Turcotte-Pugh scoring system:

Answer 35

``` ABE APP: Ascites Bilirubin Encephalopathy Albumin PT/INR Primary biliary cirrhosis ```

Question 36

Lab tests for liver function:

Answer 36

``` AAAA B CC NP: Ammonia AST/ALT Alk phos/GGT Albumin Bilirubin CBC Coags 5' Nucleotidase Prothrombin ```

Question 37

Physical assessment for liver function:

Answer 37

``` Look for: Jaundice Ascites Dependent edema Asterixis ```

Question 38

Anesthetic considerations for liver disease:

Answer 38

Often have enzyme induction and need ↑ sedatives Hyperdynamic circulatory state ↑ levels of endogenous vasodilators like VIP

Question 39

Liver disease effects on respiratory status:

Answer 39

Ascites impairs diaphragm movement and ↓ FRC

Question 40

Factors dependent on Vitamin K:

Answer 40

II, VII, IX, X | 2, 7, 9, 10

Question 41

Absorption of Vitamin K depends on:

Answer 41

Bile salt excretion into the GI tract

Question 42

Treatment of Hep B/C:

Answer 42

Interferon, ribavirin

Question 43

Treatment of AI hepatitis:

Answer 43

Corticosteroids, AZT

Question 44

Anesthetic considerations for hepatitis:

Answer 44

Aspiration precautions! | Look for s/s of encephalopathy, bleeding, ascites, etc.

Question 45

Hours after ETOH withdrawal that tremors may be seen:

Answer 45

6-8 hours

Question 46

Hours after ETOH withdrawal that seizures may be seen:

Answer 46

24 hours

Question 47

Hours after ETOH withdrawal that DTs may be seen:

Answer 47

72 hours (but preceded by tremors, hallucinations, seizures)

Question 48

Anesthetic considerations for cirrhosis:

Answer 48

Hyperdynamic circulation ↑ CO ↓ PVR

Question 49

Clotting factors reduced in liver failure:

Answer 49

II, V, VII, IX, X | 2, 5, 7, 9, 10

Question 50

Factors dependent on Vitamin K:

Answer 50

II, VII, IX, X (2, 7, 9, 10) | Protein C, Protein S

Question 51

Clotting factors reduced in liver failure:

Answer 51

II, V, VII, IX, X (2, 5, 7, 9, 10)

Question 52

Mechanism of platelet dysfunction in liver failure:

Answer 52

Thrombopoietin is produced by the liver and signals for platelet production in the bone marrow