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Gastrointestinal and Genitourinary Assessment : 

Gastrointestinal and Genitourinary Assessment Maribeth Massie, CRNA, MS, PhD(c) University of New England Nurse Anesthesia ANE 612 Physical Assessment

Physical Exam : 

Physical Exam Preoperative assessment: Obtain health history related to GI issues ROS: consider asking about the following areas based on initial health history Trouble swallowing, heartburn Appetite changes, nausea, vomiting, indigestion Frequency of bowel habits, rectal bleeding, diarrhea, constipation Jaundice, hepatitis, liver or gallbladder trouble Abdominal Note distention, masses, ascites May predispose to regurgitation or compromise ventilation

Abdominal Anatomy : 

Abdominal Anatomy

Abdominal inspection : 

Abdominal inspection

Abdominal examination techniques : 

Abdominal examination techniques

Other abdominal examination techniques : 

Other abdominal examination techniques

Liver : 

Liver ** MCL=Mid clavicular line

Liver Anatomy : 

Liver Anatomy

Spleen : 

Spleen

Chest to Spleen Anatomy : 

Chest to Spleen Anatomy

Gastroesophageal Reflux Disease (GERD) : 

Gastroesophageal Reflux Disease (GERD) Chronic symptom of mucosal damage caused by gastric acid coming from stomach up to esophagus Caused by changes in barrier between stomach and esophagus, including relaxation of lower esophageal sphincter Hiatal hernia Increase risk of pulmonary aspiration Ask about burning/chest pain sensation, sour taste in mouth

GERD Junction : 

GERD Junction

Mendelson’s syndrome : 

Mendelson’s syndrome Aspiration prophylaxis to prevent Mendelson’s syndrome (chemical pneumonitis) pH < 2.5 Gastric volume > 25 ml Most critical factor is pH of gastric contents

Medications to reduce the risk of pulmonary aspiration : 

Medications to reduce the risk of pulmonary aspiration Histamine (H2) antagonists: produce dose-related decrease in gastric acid production Cimetidine (Tagamet) 200-400 mg po, IM, IV Ranitidine (Zantac) 150-300 mg po or 50-100 mg IV Mulitdose (night before surgery and morning of) most effective IV onset < 1 hour

Medications to reduce the risk of pulmonary aspiration : 

Medications to reduce the risk of pulmonary aspiration Proton pump inhibitors: reduce acid production but do not work quick enough to be administered preop Omeprazole 20 mg po(night before surgery) Nonparticulate antacids: slightly increases gastric pH Bicitra (sodium citrate/citric acid) 30-60 ml Administer 30 min before induction Metoclopramide (Reglan): enhances gastric emptying by increasing LES tone and relaxing pylorus 10 mg po or IV administered 1-2 hours before surgery

Renal Anatomy : 

Renal Anatomy

Renal system : 

Renal system Preoperative assessment: Obtain health history to assess for GU issues Extent of renal disease Assess for polydipsia, polyuria, dysuria, edema, dyspnea, nocturia, burning or pain on urination, hematuria, incontinence Urinary infections, stones Estimate of creatinine clearance

Physical Exam : 

Physical Exam

Renal disease : 

Renal disease Pre-renal oliguria: decreased kidney perfusion resulting from dehydration or cardiac output problems Renal oliguria: may occur from pre-renal problems and leads to parenchymal disease like acute tubular necrosis Post-renal oliguria: obstructive problems with urine outflow

Acute Renal failure (ARF) : 

Acute Renal failure (ARF) Also known as acute kidney injury (AKI) Clinical manifestations of isolated or multiple insults to kidney Identified by RIFLE acronym (in clinical trials) Classification based on degree of elevation of serum creatinine (SCr) or GFR, severity and duration of oliguria, and dialysis requirements Preventive strategies can be employed periop to decrease development or risk of renal disease Preop optimization of renal function, fluid balance, and renoprotective pharmacologic agents

Acute Renal Failure : 

Acute Renal Failure Patient factors Advanced age Hypertension: poorly controlled diastolic HTN and isolated systolic hypertension Diabetes mellitus Ventricular dysfunction Sepsis Hepatic failure Chronic kidney disease

Risk, Injury, Failure, Loss, and End-Stage Kidney (RIFLE) Classification : 

Risk, Injury, Failure, Loss, and End-Stage Kidney (RIFLE) Classification

Chronic renal failure (CRF) : 

Chronic renal failure (CRF) Progressive, irreversible deterioration of renal function that results from wide variety of diseases DM leading cause of ESRD followed by systemic hypertension GFR < 25 ml/min leading to ESRD requiring dialysis and/or kidney transplant

Stages of chronic renal failure : 

Stages of chronic renal failure

Complications of Renal Disease : 

Complications of Renal Disease Preop considerations Metabolic acidosis Diabetes Anemia Bleeding Increased gastric acid and volume Increased PONV Gastroparesis Delayed emptying Friable mucus membranes GI bleeding Poor nutritional status

Complications of Renal Disease : 

Complications of Renal Disease Preop considerations Hypertension Increased cardiac output Fluid overload CAD, LVH, IHD, CHF Leukocyte dysfunction increased infection Electrolyte disturbances: Hyperkalemia Hypocalcemia Hyperphosphatemia Hypermagnesemia

Goals of anesthetic management : 

Goals of anesthetic management Evaluate renal function Preserve renal integrity Prevent renal failure Provide adequate hydration Diuretics Avoid hypotension and use of nephrotoxic agents Maintain BP 80-180 mmHg to prevent changes in GFR Labs

Preop assessment of dialysis patients : 

Preop assessment of dialysis patients Need to ask questions regarding dialysis When was last dialysis? How often? What is access? Assess for bruit and thrill pre-and post-op Do not take BP, IV access on AV fistula extremity; do not tuck too tightly Any hemodynamic instability with dialysis? Does the patient make any urine? What is patient’s dry weight? Should undergo dialysis within 24 hours before elective surgery

Preop Preparation : 

Preop Preparation IV fluids: 0.9% or 0.45% NS Hang 500 ml bags and use microdrip tubing to avoid accidental overload If hematocrit low, replace volume loss with transfusion instead of crystalloids Recombinant human erythropoietin If hypotensive, treat with vasopressors Avoid elective surgery if potassium >5.5 mEq/L Consider RSI with cricoid pressure

Renal preop assessment : 

Renal preop assessment Check electrolytes Bring injectable dye into room if physician requests it Indigo carmine: causes temporary blood pressure increase and drop in pulse ox sat; can have allergic reaction Methylene blue: can cause hypotension

Medications : 

Medications Succinylcholine can be given if potassium normal Dialysis can lower serum cholinestarase so prolonged effect of Sux Safe NDMR Atracurium Cisatracurium Rocuronium Vecuronium Volatile agents decrease cardiac output Opioids, sedatives, barbs prolonged effect

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