Nutritional and Gastrointestinal Disease

Chapter 26 Nutritional and Gastrointestinal Disease



Steve Hyman, William R. Furman



Obesity




1. What is a desired body mass index (BMI)? What BMI defines morbid obesity? What BMI defines “super obese”? What BMI defines “super-super obese”?


2. What organ systems can be affected by obesity?


3. What is the metabolic syndrome and what is its significance?


4. How is the diagnosis of metabolic syndrome made?


5. What are the contributory factors to morbid obesity?


6. What are four main considerations when anesthetizing a morbidly obese patient?


7. What were some of the complications with the older weight loss operations such as jejunoileal bypass?


8. What are three significant and beneficial effects of modern gastric bypass?



Malnutrition




9. What is the definition of malnutrition? Why might malnutrition be present in surgical patients?


10. Is enteral or intravenous nutrition preferable for most patients who require supplemental feedings? Why?


11. What is refeeding syndrome? What is the pathophysiology of refeeding syndrome? What are the signs of refeeding syndrome?


12. What are four perioperative considerations for the malnourished patient? What are the considerations for the critically ill enterally fed patient?



Inflammatory bowel disease




13. What is the presumed pathophysiology of inflammatory bowel disease (IBD)? What are some of the factors that are associated with IBD?


14. What are the major differences between ulcerative colitis and Crohn’s disease?


15. What is the preferred anesthetic technique for a patient with IBD?


16. How do drugs used in the treatment of IBD interact with anesthetic drugs?



Gastroesophageal reflux disease




17. What is the definition of gastroesophageal reflux disease (GERD)?


18. What is the pathophysiology of GERD?


19. What are the signs and symptoms of GERD?


20. What is the risk of pulmonary aspiration on induction of anesthesia?


21. Does the rapid sequence induction (RSI) with cricoid pressure (Sellick maneuver) prevent pulmonary aspiration? Why or why not?


22. What is the mechanism of development of subcutaneous emphysema, pneumomediastinum, or pneumoperitoneum after a Nissen fundoplication?



Diabetes mellitus




23. What is the definition of diabetes? What types of complications are associated with long-term poorly controlled diabetes?


24. What is autonomic neuropathy? What perioperative risks are associated with autonomic neuropathy?


25. Why are the historical classifications of insulin-dependent and noninsulin-dependent diabetes inferior to type 1 and type 2 diabetes?


26. What is the major treatment goal in both types of diabetes?


27. What are the four categories of oral hypoglycemic agents?


28. What is hemoglobin A1C (glycosylated hemoglobin)? What is its significance in the management of diabetes?


29. What is the recommended management of preoperative diabetes medicines?


30. What blood glucose levels should be maintained perioperatively? What are some potential complications of severe perioperative hyperglycemia?


31. At what level of preoperative glucose should an operation be postponed?



Hyperthyroidism (thyrotoxicosis) and thyroid storm




32. What is the definition of hyperthyroidism?


33. What are some common causes of hyperthyroidism?


34. What is Graves’s disease?


35. What are the signs and symptoms of hyperthyroidism?


36. What is the difference between hyperthyroidism and thyroid storm?


37. What are the signs and symptoms of thyroid storm?


38. What conditions may cause a thyrotoxic patient to develop thyroid storm?


39. What medications are used in the management of thyroid storm?


40. What is the Wolfe-Chaikoff effect?


41. What are the anesthetic considerations for a patient with hyperthyroidism?


42. How should perioperative thyroid storm be managed?



Hypothyroidism




43. What is the definition of hypothyroidism?


44. What are the causes of hypothyroidism?


45. What are the signs and symptoms of hypothyroidism?


46. What is the difference between primary and secondary hypothyroidism?


47. What are the airway considerations (both preoperative and postoperative) in a patient undergoing thyroid surgery?


48. Is it necessary to delay surgery in hypothyroid patients and achieve a euthyroid state before operating?


49. What is intraoperative laryngeal nerve monitoring and what is its impact on the anesthetic plan?



Pheochromocytoma and paraganglioma




50. What is the embryologic cell of origin of the pheochromocytoma and what is the difference between it and a paraganglioma?


51. What hormones are produced by these tumors and what are their common signs and symptoms?


52. How common are pheochromocytomas and paragangliomas tumors?


53. How should perioperative hypertension and tachycardia associated with pheochromocytoma and paraganglioma be managed?



Multiple endocrine neoplasia and neuroendocrine tumors




54. What is the MEN-1 (multiple endocrine neoplasia-1) syndrome? What is its inheritance pattern?


55. What is the MEN-2 (multiple endocrine neoplasia-2) syndrome? What is its inheritance pattern?


56. What specific tumors are commonly found in patients with MEN-1?


57. What are the subtypes of MEN-2?


58. What are the anesthetic implications of MEN-1 and MEN-2?


59. What are carcinoid and neuroendocrine tumors and what hormones do they produce?


60. Why are midgut carcinoid tumors often asymptomatic? When do they become symptomatic?


61. What is carcinoid syndrome? What is the usual treatment for a carcinoid crisis?


62. What are the perioperative implications of carcinoid and neuroendocrine tumors?



Adrenal insufficiency and steroid replacement




63. What are the principal hormones of the adrenal cortex?


64. What is the mechanism by which stress stimulates the release of cortisol?


65. What is the function of cortisol in the body?


66. What is Addison’s syndrome? What are the symptoms?


67. What is the difference between primary and secondary (or tertiary) adrenocortical insufficiency?


68. What are the frequent causes of primary adrenocortical insufficiency?


69. What are the frequent causes of secondary or tertiary adrenocortical insufficiency?


70. What is addisonian crisis (acute adrenal failure)? What are its symptoms and causes?


71. What are the common causes of pituitary apoplexy? What are the signs, symptoms, and treatment of pituitary apoplexy?


72. What is the effect of etomidate on adrenal function?


73. What is the general approach to perioperative steroid replacement in the patient who has steroid-induced adrenal insufficiency?


74. What is critical illness-related corticosteroid insufficiency (CIRCI)?



Cushing’s syndrome




75. What is Cushing’s syndrome? What are the signs and symptoms of Cushing’s syndrome and how is it diagnosed?


76. What is the difference between primary and secondary (or tertiary) Cushing’s syndrome?


77. What is the difference between Cushing’s syndrome and Cushing’s disease?


78. What are the common causes of secondary Cushing’s syndrome?


79. What are the anesthetic considerations in a patient with Cushing’s syndrome?



Answers*



Obesity




1. A desirable BMI is generally considered to be 18 to 25. Morbid obesity is a BMI of 40 or more. Super obese is a BMI of 50 or more and super-super obese is a BMI of 60 or more. (463)


2. Morbid obesity can affect virtually any organ system of the body. Commonly affected systems are cardiovascular (hypertension, stroke, right heart failure), endocrine (reproductive hormonal imbalances, impaired fertility, diabetes), and gastrointestinal (hiatal hernias and gastroesophageal reflux from increased intraabdominal pressure). Involvement of the pulmonary system can include low residual volumes, rapid desaturation, restrictive lung disease, and obstructive sleep apnea. Skeletal problems may include back pain and osteoarthritis, particularly of the knees. Some malignancies (colon and breast) are associated with obesity as are some psychological disorders such as depression. (463)


3. Metabolic syndrome is a term that applies to the combined complications of obesity. There are six components of the metabolic syndrome: abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, insulin resistance (glucose intolerance), a proinflammatory state, and a prothrombotic state. Diagnosis and treatment is important because it alone predicts approximately 25% of all new-onset cardiovascular disease. (463-464)


4. Diagnosis of metabolic syndrome is made by the presence of three out of five of the following: abdominal obesity, elevated triglycerides, low HDL, elevated blood pressure, elevated fasting glucose. (463)


5. The causes of obesity are multifactorial. They include genetic, environmental, metabolic, and psychosocial factors. While caloric consumption is important, the urge to eat (or overeat) can be modulated by hormones. Fasting releases several orexigenic (appetite-stimulating) hormones and can cause inflammation. (464)


6. Four major considerations in the anesthetic management of the morbidly obese patient include the risk of aspiration of gastric contents, securing the airway, the logistics of caring for a large patient, and emergence technique.


In the 1970s, it was suggested that fasted obese patients might have larger than normal gastric volumes with a lower than normal pH. This assertion was not supported with strong scientific evidence. More recent studies appear to show that nondiabetic obese patients actually may have less volume at a higher pH than do lean nondiabetic patients.


The most basic tasks may be difficult in the obese patient. Peripheral intravenous line placement may be difficult and central venous catheterization may be required. Blood pressure monitoring may be difficult because of the conical shape of the upper arm. Most blood pressure cuffs are designed for a more cylindrical profile and may not remain in position or function optimally on a cone-shaped arm. Practical options include a cuff on the forearm or calf, or an intraarterial catheter.


Positioning is difficult because obese patients may be wider than the horizontal surface of the operating table. Also, the table must be able to support the patient’s weight and move into required positions for surgical access. Extreme positions of tilt demand that the patient be well secured and that potential pressure points be addressed.


Obesity is reported to increase the risk of a difficult laryngeal intubation. One recent study found the intubation difficulty score to be higher in obese patients, but time to intubation and SpO2 levels to be the same as in lean patients. However, there is evidence that difficult intubation correlates better with male gender and a higher Mallampati airway evaluation score, as in the general population.


During intubation, diminished functional residual capacity may lead to rapid desaturation. A reverse Trendelenburg position (head up) can reduce atelectasis in dependent lung areas and can help move chest, and breast tissue caudally, allowing easier access to the mouth for intubation.


No induction or maintenance drug has a distinct advantage in the obese patient. Emergence can be slow because of a reduced rate of elimination of volatile anesthetic agents from adipose tissues. (464)


7. Unlike current operations that restrict the gastrointestinal tract, the jejunoileal bypass developed in 1954, was a malabsorptive operation developed for the treatment of hyperlipidemia, atherosclerosis, and obesity. It was abandoned by the 1980s because it causes unacceptable complications, including uveitis, kidney dysfunction, intestinal bacterial overgrowth, and liver damage. (464)


8. Gastric bypass patients generally have improvements in quality of life and comorbidities. There is improvement in hypertension, diabetes, and/or obstructive sleep apnea. Several orexigenic (appetite stimulating) hormones are diminished by bariatric surgery. Ghrelin secretion by the gastric fundus and proximal small intestine is increased after nonsurgical weight loss but is unchanged or decreased after bariatric surgical procedures. Other intestinal hormones that regulate appetite and glucose metabolism also are affected favorably by surgery. These include glucagon-like peptide-1, glucose-dependent insulinotropic peptide, and peptide YY. (464)



Malnutrition




9. Malnutrition may be present when there is weight loss of 10% to 20% over a short time, when weight is less than 90% of ideal body weight, or when BMI is less than 18.5. Healthy patients may quickly become malnourished after an accident or acute illness and critically ill patients develop malnutrition if they are not fed. Malnutrition can occur quickly when caloric requirements exceed intake due to decreased intake, impaired absorption, or an increased metabolic rate. (464-465)

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May 31, 2016 | Posted by in ANESTHESIA | Comments Off on Nutritional and Gastrointestinal Disease

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