A small compilation of nurse anesthesia care plans

These anesthesia care plans are meant to inspire nurse anesthesia residents when they are making their care plans. Always make sure you fully understand and "own" your care plan. Your plan must be specific for your patient and should always be with the most up-to-date information.

Gastroesophageal Reflux Disease (GERD)

Overview

Reflux of gastric contents into the esophagus is associated with symptoms.

The esophagus extends from C6 to LES.

The esophagus has three functional zones:

  • The upper esophageal sphincter (UES)
    • The UES is in a state of tonic contraction around 15-60 cm H2O, preventing air into the esophagus
    • Function is impaired during sleep and anesthesia
      • Causing an increased risk of aspiration except with the use of Ketamine
  • The esophageal body
  • The lower esophageal sphincter (LES)
    • LES is about 3cm wide with a tone around 10-15 cm H2O or 20-25 mmHg
    • Part of the barrier pressure, which is the pressure gradient between LES and gastric pressure (5-10 mmHg)

High intragastric pressure can lead to reflux into the esophagus and increased aspiration risk.

Optimal preoperative conditions have gastric volume <0.4 mL/kg and gastric pH >2.5, which is part of the reason for NPO and premeditations to minimize the risk of aspiration pneumonia. Normal gastric pH 1-3.5.

Anesthesia considerations

Increased risk of aspiration

The urgency of surgery, airway problems, light anesthesia, lithotomy position, diabetes, pregnancy, and obesity lead to increased abdominal pressure.

Patients with reflux disease often have associated respiratory symptoms (laryngitis, recurrent pneumonia, progressive pulmonary fibrosis) along with heartburn and regurgitation.

Drug Considerations

Decrease LES pressure: thiopental, propofol, opioids, anticholinergics, and inhaled anesthetics.

Increase LES pressure: antiemetics, cholinergics, antacids, and succinylcholine.

Nondepolarizing muscle relaxants and H2-receptor antagonists do not affect LES pressure.

Premedication options

Zantac 150 mg po

H2 blocker - blocks histamine = decreased acid production in stomach = increased pH) Lasts 3 hrs

Reglan 10 mg po

Increases mobility

Alka-Seltzer Gold 2 tabs with 30 mL of water

The goal is to increase stomach PH to >2.5 before intubation to decrease the severity of aspiration pneumonia  

Omeprazole (proton pump inhibitor) should be given the night before

Sodium citrate (non-particulate) should be given with prokinetic and only to morbidly obese, pregnant, or diabetic patients.

This combination elevates pH to >2.5 and ensures <25 mL of gastric contents

Neutralizes gastric acid. Note high sodium content of 1meq/ml) - dilute with water to prevent N/V

Elevate the head during intubation. Consider using cricoid pressure and performing RSI (controversial since Succinylcholine increases LES tone, and cricoid pressure decreases LES tone).

Insert NG tube post intubation to manage GI secretions. Consider antiemetic.

If possible, transport the patient to PACU on the side and have suction readily available.