1
Q
Upper GI Endoscopy =
A
Esophagogastroduodenoscopy (EGD)
2
Q
EGD: Purpose
A
Diagnostic/therapeutic
3
Q
EGD: most common position
A
Left lateral decubitus most common
4
Q
Porphyria Safe or Unsafe Drug:
Phenacetin
A
UNsafe
5
Q
What is an EGD
A
Flexible scope into esophagus to small intestine
6
Q
T/F: We always use sedation/anesthesia for EGD procedures
A
False.
+/- sedation/anesthesia
7
Q
EGD: Share the airway
A
- Natural airway- avoid apnea, jaw lift, O2 nasal cannula
- Vs. GA w/ ETT
- Cardiopulmonary complications most common
8
Q
EGD: When is the bite block placed?
A
Bite block placed:
Prior to sedation
OR
if GA, after ETT placement
9
Q
Porphyria Safe or Unsafe Drug:
Locals
A
Safe
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
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
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
13
Q
Porphyria Safe or Unsafe Drug:
Calcium Channel Blockers
A
UNsafe
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)
15
Q
Hiatal hernia
A
- Herniation of stomach into thoracic cavity
- May be asymptomatic
- +/- RSI w/ cricoid, ETT
- OGT
- Awake extubation
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)
17
Q
What is aspiration pneumonitis?
A
Aspiration pneumonitis =
volume 0.4-0.5 mL/kg of gastric contents & PH < 2.5.
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
19
Q
Porphyria Safe or Unsafe Drug:
Inhalational agents
A
Safe
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
21
Q
Lower GI bleeding
A
Colonoscopy after bowel prep for evaluation
22
Q
Crohn’s Disease
A
- Inflammation of all layers of the bowel
- May lead to fistula development
- Fear of eating, anorexia, diarrhea, pain
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
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)
25
Colonoscopy
* Diagnostic and/or therapeutic
* Typically **left lateral decub**itus
* +/- sedation/anesthesia
* May be combined w/ EGD
* If completed in isolation- generally natural airway
* Bowel prep and **dehydration** is major concern
26
Acute Pancreatitis
* 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
27
Porphyria Safe or Unsafe Drug:
Insulin
Safe
28
Porphyria Safe or Unsafe Drug:
NDMR
Safe
29
Chronic Pancreatitis
* 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
30
Considerations for Pancreatitis
* **DM** management
* Aggressive **fluid** administration even for mild cases
* **Colloid** replacement
* **Pain control**
* NGT/OGT *prior to induction*
* RSI +/-
31
What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)
* 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**.
32
ERCP Anesthesia Considerations
* _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
33
What are carcinoid tumors?
* Originate in GI tract most of time
* Secrete corticotropic hormones, GI peptides, prostaglandins and bioactive amines (serotonin)
34
Carcinoid syndrome
* Systemic release of serotonin and vasoactive substances
* Flushing and diarrhea
* Dehydration and electrolyte disturbances
* Hypotension, HTN
* Bronchoconstriction
* Occasional R side heart manifestations
35
Carcinoid syndrome is usually precipitated by...
Precipitated by:
* stress
* exercise
* alcohol
* catecholamines
* serotonin reuptake inhibitors
36
What is carcinoid crisis?
* Potentially life threatening
* Intense flushing, diarrhea, abd pain, tachycardia, hypo or hypertension
* Spontaneous or provoked by:
* Stress
* Chemotherapy or tumor biopsy
* Certain drugs
37
Carcinoid tumor treatment
* Somatostatin analogue **octreotide**
* **Resection** of tumor by surgery
38
Carcinoid Tumor Anesthetic Management
* 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
39
Drugs that provoke mediator release (carcinoid tumor)
* succinylcholine
* mivacurium, atracurium, tubocurarine
* epi, norepi, dopamine, isoproterenol
* thiopental
* b-agonists
* histamine releasers
* ketamine
40
Porphyria Safe or Unsafe Drug:
Opioids
Safe
41
Anesthesia for Bowel Obstruction
* **_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
Acute Cholecystitis
* 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
* **Lap**aroscopic → 5% convert to open
* **ERCP**
43
Laparoscopic Procedures
* 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
Porphyria Safe or Unsafe Drug:
Etomidate
UNsafe
45
Considerations for Laparoscopic Procedures
* 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
Hepatitis
* 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
Acute vs Chronic Hepatitis
* **_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
What is cirrhosis
Chronic, progressive parenchymal damage leads to scarring and nodular formation
49
S&S of cirrhosis
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
Porphyria Safe or Unsafe Drug:
PCN
Safe
51
Cirrhosis: Labs
* _Elevated_:
* Bilirubin
* Aminotransferase
* Alkaline phosphatase
* INR
* _Decreased_:
* Serum albumin
* Platelets
* Blood sugar
52
Cirrhosis: Child-Pugh Score
* 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
What labs/assessments does Child-Pugh score look at?
Total bilirubin
serum albumin level
INR
ascites
hepatic encephalopathy
54
Cirrhosis Anesthetic Considerations:
Preop Optimization
* **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
List the anesthetic considerations for cirrhosis
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
Porphyria Safe or Unsafe Drug:
Amiodarone
UNsafe
57
Cirrhosis: Anesthetic Considerations
Encephalopathy
* RSI
* Judicious use of sedatives and induction agents
58
Cirrhosis: Anesthetic Considerations
Ascites
* RSI
* Mechanical ventilation
* PFTs
* PA pressures
* Fluid status: *For every 1 L of ascites removed, need 8g of albumin given*
59
Porphyria Safe or Unsafe Drug:
Most CV drugs
Safe
60
Cirrhosis: Anesthetic Considerations
Esophageal Varices
* _No_ esophageal temp probe or NG/OGT
* _Bleeding_? → RSI
* **Octreotide (50 mcg/hr)** or
* **Vasopressin (20 U over 5 min)**
61
Cirrhosis: Anesthetic Considerations
Renal Impairment
* **Euvolemia**
* Monitor and correct for a**cid-base and electrolyte** imbalances
* *Refer to renal lecture for renal considerations*
62
Cirrhosis: Anesthetic Considerations
Hyperdynamic Circulation
* ↓ 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
Cirrhosis: Anesthetic Considerations
Coagulopathy
* **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
Cirrhosis: Anesthetic Considerations
Pharmacokinetics
* **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
Porphyria Safe or Unsafe Drug:
Propofol
Safe
66
Cirrhosis: Anesthetic Considerations
Maintain Liver Blood Flow
* **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
Porphyria Safe or Unsafe Drug:
Ketorolac
UNsafe
68
Post-Op: Cirrhosis
* Post-op morbidity is ↑
* Liver dysfunction/failure (#1)
* Renal failure
* Bleeding
* DTs
* Electrolyte disturbances
* Pneumonia
* Sepsis
* Poor wound healing
69
Porphyria Safe or Unsafe Drug:
Nifedipine
UNsafe
70
Alcoholism
* **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
Porphyria Safe or Unsafe Drug:
Barbiturates
UNsafe
72
Alcohol Withdrawal Syndrome:
S&S
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
Alcohol Withdrawal Syndrome:
Treatment
* **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
Porphyria
* 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
What are porphyrins?
* 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
Acute Intermittent Porphyria
* Most serious
* Attacks **life threatening**
* Affects central and peripheral nervous system
* **Systemic HTN** and **renal dysfunction**
77
Porphyria: Triggers
* 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
Porphyria: S&S
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
Porphyria: Treatment
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
Porphyria Safe or Unsafe Drug:
Diazepam
UNsafe
81
Anesthetic Management of Porphyria
* _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 vent**ilation
* Minimize stress of preop _fasting_ **glucose-saline infusion**
* **Fluid/electrolyte** management
82
Porphyria Safe or Unsafe Drug:
ASA/APAP
Safe
83
Porphyria Safe or Unsafe Drug:
Glucocorticoids
Safe
84
Porphyria: Regional
Regional
* No absolute contraindications
* Avoid in acute exacerbation
* Pre-anesthetic neuro eval
* ANS blockade may lead to CV instability especially w/ hypovolemia
85
Porphyria Safe or Unsafe Drug:
Sulfonamide antibiotics
UNsafe
86
Porphyria Safe or Unsafe Drug:
ETOH
UNsafe
87
Porphyria Safe or Unsafe Drug:
Atropine/Glycopyrrolate
Safe
88
Porphyria: General
General
* Use short acting agents
* _Induction_ w/ propofol
* _Maintenance_ w/ N2O, inhaled anesthetics, opioids and NDMR
* Monitors!
* Cardiopulmonary bypass is a stressor
89
Porphyria:
SAFE Drugs
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
Porphyria:
UNsafe Drugs
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
Porphyria Safe or Unsafe Drug:
Neostigmine
Safe
92
Porphyria Safe or Unsafe Drug:
Ketamine
UNsafe
93
Porphyria Safe or Unsafe Drug:
Benzodiazepines
Safe
94
What are the most common cardiopulmonary complications from EGD?
* Desats
* Airway obstruction
* Laryngospasms
* Aspiration
95
S&S CO2 embolism (lap procedure)
* Similar to VAE
* Drop in etCO2
* Hypotension
* Tachycardia
* Arrythmias
* Wind mill murmur
Coexisting
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