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117 Cards in this Set
- Front
- Back
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ONE OF THE TOP THREE CAUSES OF LAWSUITS
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Inadequate preop assessment is now one of the top three causes of lawsuits!
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TYPES OF SURGERY THAT ARE LOW RISK < 1%
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skin, breast, urologic, and minor ortho, cataract surgery
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TYPES OF SURGERY THAT ARE INTERMEDIATE RISK <5%
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abdominal (lap chole, intrathoracic, ortho, and carotid
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High risk – usually >5%
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emergent, aortic and other vascular surgery (AAA, CABG), anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
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Anesthesia History: any complications
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MH, slow wakeup, nausea/vomiting, difficult airway
Family History Inheritable diseases |
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NPO Guidelines
LONGER FOR... |
Longer for pregnant, DM, renal pts, hx of GERD, hiatal hernia, esophageal narrowing
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NPO GUIDELINES
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Clear Liquids (water, pulp-free juice, clear tea, black coffee, carbonated beverages) 2 HOURS
Breast milk 4 HOURS Infant formula/nonhuman milk 6 HOURS Light meal (toast, crackers, clears) 6 HOURS Fried/fatty foods, meat > 8 HOURS |
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TYPES OF ANAPHYLAXIS
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Type I – immediate hypersensitivity reaction; IgE mediated release
Atopic – dermatitis, allergic rhinitis Anaphylactoid – generalized hives, edema, erythema associated with antigen-antibody process 25% will get allergic rxn to cefazolin—give vanco or clindamycin(less SE than vanco) Do not push clinda will get IGG rxn Shellfish/seafood: not linked to IV iodine contrast allergy Dermatitis after topical iodine may alert to IV allergy |
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WHICH BLOOD PRESSURE MED WOULD YOU TELL A PATIENT TO HOLD DAY OF SURGERY?
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ACE inhibitors, especially angiotensin II antagonists (AIIAs)
ACE inhibitors were associated with hypotension in 100% of pts during induction vs. only 20% in whom ACE inhibitors were withheld on morning of surgery (1994) Bertrand and colleagues demonstrated severe hypotensive episodes requiring vasoconstrictive therapy after induction in pts chronically treated with an AIIA and receiving this drug on morning of surgery than in those whom AIIAs were withheld day before and morning of surgery |
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WHICH DRUGS SHOULD A PATIENT CONTINUE TO TAKE MORNING OF SURGERY?
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Antihypertensive
Antianginals Antiarrhythmics Anticonvulsants (Alter the hepatic metabolism of many drugs and induce cytochrome P450 enzyme activity) Hormone therapy |
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ORAL HYPOGLYCEMIC MEDS AND DAY OF SURGERY?
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Oral hypoglycemic medications - may produce hypoglycemia for long as 50 hours after intake
TOLINASE, ORINASE, MICRONASE, GLUCOTROL, DIABINESE Implanted insulin pump - ask pt how controlled is diabetes; ask rate; time of surgery; time usually between each meal insulin pump just decrease the dose in half. |
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Discontinue drugs
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NSAIDS – seven days
ASA – should be stopped 10-14 days before surgery Coumadin/Plavix – up to surgeon; PT/INR; usually within 24 hours Tricyclics/MAOI’s – if possible stop 2 weeks prior; or continue but no indirect acting sympathomimetics or demerol |
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Tricyclics/MAOI’s
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if possible stop 2 weeks prior; or continue but no indirect acting sympathomimetics or demerol
Excitatory or depressive interaction Excitatory – agitation , headache, hemodynamic instability, fever, rigidity, convulsions, and coma - Thought to be due to excessive central serotoninergic activity – meperidine blocks neuronal uptake of serotonin Depressive – respiratory depression, hypotension, and coma as result of MAOI inhibition of hepatic microsomal enzymes and meperidine accumulation |
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LIFE SPAN OF A PLATELET
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11 DAYS
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Steroids
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If on supplemental steroids >one month, give stress dose
100mg on induction, then 50 mg every 6 hours x , or Stoelting, 25mg on induction then total of 100mg over next 24 hours Minimum drug dose that would produce and appropriate effect is desirable Avoid Etomidate!! Steroids for at least a month long for less than 6 months ago. |
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Alzheimer’s therapy
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prolongs sux
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Lithium
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potentiates NMB; check sodium level
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Clonidine
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decreases anesthetic requirements
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Aminoglycosides
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potentiates NMB
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HIV meds (protease inhibitors end with “vir”):
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potentiate versed
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Recommendation is to D/C herbals
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2 weeks before surgery
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Echinacea (echinacea purpura
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Increased toxicity of drugs dependent on hepatic metabolism (phenytoin, phenobarbital, rifampin)
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Garlic (Allium sativum)
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Uses: Lipid lowering, vasodilatory, antihypertensive, antiplatelet, antioxidant, antithrombotic/fibrinolytic qualities
Issues: Inhibition of platelet aggregation Increased fibrinolyismay increase risk of bleeding |
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Ginkgo (Gingko biloba)
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Uses: circulatory stimulant, antioxidant, anti-inflammatory effects; used to treat claudication, tinnitis, vertigo, memory loss, dementia, sexual dysfunction
Issues: Inhibition of platelet activating factor may increase risk of bleeding May decrease effectiveness of anticonvulsants |
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Ginseng (Panax ginseng)
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Uses: enhances energy level, anitoxidant, aphrodisiac; lowers blood glucose
Issues: Ginseng abuse syndrome: sleepiness, hypertonia, edema; also tachycardia, hypertension with other stimulants Intraop hypotension Hypoglycemia in diabetics Inhibition of platelet aggregation May interfere with effect of warfarin makes effects more |
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Kava-kava (Piper methysticum)
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Uses: sedation, anxiolysis; treatment for gonorrhea, skin diseases
Issues: May inhibit norepinephrine Potentiates sedating effects of barbiturates, benzos, alcohol |
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Saw Palmetto (Serenoa repens)
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Uses: treatment for BPH
Issues: Inhibition of 5-α reductase Inhibition of cyclooxygenasemay increase risk of bleeding |
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Vitamin E
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Uses: slows aging process, prevention of stroke and pulmonary emboli, prevention of atherosclerosis, promotion of wound healing
Issues: May increase bleeding |
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TIAs
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5% - 6% annual mortality rate after TIAs is due to mainly MI
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Parkinson’s
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Avoid drugs that inhibit release of dopamine or compete with dopamine at the receptor avoid reglan***
Reglan causes pyramidal side effects like shaking and drooling |
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Dementia/Alzheimer’s
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Usually on cholinergic mediations
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PORPHYRIA
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– type 1,3, and 4, could cause life threatening neurologic abnormalities (THIOPENTAL & SULFA CAUSES IT)
Autosomally inherited lack of functional enzymes active in the synthesis of hemoglobin Certain drugs can induce the enzyme ALA synthetase – exacerbating the disease Colicky pain, n/v, severe constipation, psychiatric disorders, and lesions of the lower motor neuron that could progress into bulbar paralysis Avoid barbiturates, diazepam, phenytoin, ergotamine prep, sulfanomides Adm glucose suppresses ALA synthetase activity and prevents and ablates acute attacks |
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Myasthenia Syndrome
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Eaton-Lambert syndrome
Associated with small cell carcinoma of lung A prejunctional defect in the release of acetylcholine; body produces antibodies against ca channels of tumor; however these antibodies cross react to ca channels at the NMjunction. Muscle weakness improves with repeated effort; unaffected by anticholinesterase drugs Sensitive to depolarizing and nondepolarizing agents |
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Myasthenia Gravis
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Destruction or inactivation of postsynaptic acetylcholine receptors leading to reduce number of NMJ sites
Unpredictable reaction to NMB Resistant to succ, but lead to phase II Sensitive to nondepolarizers Good response to anticholinesterases EX: pyridostigmine tx (NMB reversal) If people use sux they are more likely to get a phase II block b/c of the larger dose. Require less of non depolarizing. They are treated with anticholinesterases, so when trying to reverse from nondepolarizers they don’t respond as well. May have an unpredictable response to the reversal. |
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MURMURS?
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20-50% number of adults with undiagnosed PDA
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Cardiovascular
Stress response of surgery |
Physiological response of surgical assault
Blood is diverted from areas of body to head & heart, BP & HR increase – CV system has to be in optimal health |
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Determination of Ischemic heart disease/CAD
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Recent MI
Perioperative infarction rate is higher in the first 6 months after a previous MI American College of Cardiology and AHA indicate a liberalization of surgery to 6 weeks after infarction to ‘low-risk pts’ Due to changes in tx of MI – thrombolytics, PTCA Six weeks will allow myocardium to heal - reduces risk of arrhythmias and rupture of ventricular aneurysms |
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Recent cardiac event
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you are more at risk in surgery for perioperative cardiac re-event.
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Conditions that could/should be corrected/stable before surgery – (ideally
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Recent MI/severe ICD
Severe CHF (rales, an S3 gallop, or JVD) Severe angina (unstable angina) Cerebrovascular disease Heart rhythm other than sinus Chronic renal insufficiency Serum creatinine > 2.0 mg/dL (at higher risk for further renal damage) |
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Does adequate control of HTN result in complications that could be prevented with some control?
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Pt should be educated regarding importance of lifelong treatment of HTN to prevent arterial aging/damage
Perioperative hemodynamic fluctuations occur less frequently in treated than untreated hypertensive pts Hemodynamic fluctuations have some relationship to morbidity |
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Pacemaker / AICD (settings, firing, manufacturer)
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Demand pacemakers can sense electrocautery therefore will inhibit pacemaker firing
Convert to fixed rate or default program – know pt’s settings, manufacturer, and type Magnet or programming device contact EPS (turns device off) Grounding pads should be as far from the generator and leads as possible; should use Bipolar cautery |
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Drug eluting stents (DES) vs bare metal stents
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Challenges with bleeding vs perioperative stent thrombosis
Cardiology consult Elective surgery should be delayed if less than 6 months since placement of DES If emergent, ASA and Plavix should be continued if possible |
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Obstructive Sleep Apnea
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Airway collapse d/t loss of muscle tone
During REM sleep – pronounced in obese pts Snoring caused by airway vibration from turbulent flow Repeated collapse (obstruction) of upper airway develops during sleep with cessation of airflow, however resp efforts continue. Obstructions and apnea lead to SNS activation and arousal from sleep, restoring muscle tone. OSA pt have 7 x increase in mortality Obesity and Plastic bottle use increase risk Review sleep study/Respiratory Distress Index (RDI) RDI > 10 monitored bed overnight vs ICU |
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ANESTHESIA AND OSA
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Anesthetic agents worsen OSA by decreasing pharyngeal tone and attenuating normal responses to hypoxia and obstruction
Supine position worsens OSA OSA pt have redundant pharyngeal tissue: difficult airway mgt Grey zone: mgt of OSA in ambulatory surgery setting GA may increase number and duration of sleep apneas Inhibits arousal which would occur during sleep Judicious use of sedatives and narcotics; use short acting agents; non steroidal analgesics if not contraindicated Difficult airway precautions Regional or local anesthesia when appropriate CPAP in PACU available |
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Smoking
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SMOKING – risk factor for cardiac and pulmonary disease
Cigarettesnicotine + carbon monoxide Nicotine – adrenergic effects Carbon monoxide – occupies oxygen-binding sites of Hgb Long Term: Hypersecretion of gastric acid and hepatic enzyme stimulation Persists for 6-8 weeks after cessation Development of obstructive airway disease Chronic bronchitis Emphysema – over production of sputum & reduction of ciliary motility & distal airway function Decreased CO only benefit of decreasing smoking hours before surgery |
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SMOKING ANESTHETIC CONSIDERATIONS
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Anesthetic considerations
Airway is hyperactive Excessive coughing & bucking Bronchospasm and rapid desaturation Cessation for 24hrsreduces carboxyhgb and may improve oxygenation Cessation 24hrs – 6 weeks increases incidence of morbidity Cessation >6weeks returns oxygenation and mucociliary clearance but not to normal. Post-op complications: atelectasis, pleural effusions, and pneumonia Post thoracic/abdominal cases Need 8 week cessation before drastic reduction of post-op complications |
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Ulcerative colitis, Crohn’s Disease
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Associated with electrolyte imbalances
Dehydrated, malabsorption & malnourished If active, could have GI bleeding, GI obstruction, perforation of colon, toxic megacolon |
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Anorexia / Bulemia
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Malnourished, dehydration, electrolyte imbalances
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Hyperthyroidism – Thyroid Storm
Does your face flush or get red every now and then, even when you’re not exercising? Hyperthyroidism? |
Tachycardia
Hyperthermia Labile blood pressure –could be dehydrated and vasodilate during induction |
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Hyperthyroidism – Thyroid Storm
Treatment |
Avoid surgery until euthyroid
Hydration and cooling Beta blocker Correction of precipitating cause Avoid anticholinergics – could interfere with normal heat regulating mechanisms Avoid ketamine, pancuronium, indirect-acting adrenergic agonist and other drugs that stimulate the SNS Increase requirements of sedatives anything that stimulates the sympathetic nervous system avoid. |
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DIABETIC ISSUES
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Increases morbidity and mortality by 5-10 times
Accelerates atherosclerosis and end organ damage Causes neuropathy, retinopathy Often has silent ischemia – painless MI 50% likelihood of autonomic nervous system dysfunction with HTN Reflex dysfunction: increase risk for CV instability Delayed gastric emptying Poor wound healing Renal insufficiency Joint collagen tissue abnormalities |
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DIABETES TREATMENT IN OR
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Schedule early surgery
Check BS in pre-op holding if brittle = every one hour in OR Type II = every 3-4 hours in OR Start IV NS (or LR is BG lower) If taken insulin or oral agent D51/2NS Check blood sugar every 1-2 hours in OR |
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if you have peripheral neuropathy you also have
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autonomic neuropathy. Sometimes people with parkinsons have this and also older people. Remember this. You would know that it was autonomic neuropathy b/c their heart rate didn’t increase which is a normal response when blood pressure drops. Tachycardia is the first sign of low blood sugar under anesthesia is tachycardia. If they are on beta blockers you won’t see this.
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DMs who use NPH
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(neutral protamine hagedorn) or protamine zinc insulin are at greater risk of allergic reaction to protamine sulfate
Massively hypotensive from protamine reaction If they have had protamine before or they are taking NPH should check a test dose to make sure that they are not going to have a protamine reaction. |
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Each cc of D50, will rise BS of a 70kg person
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2mg/dl approx.
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If fragile diabetic
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Start IV D5W at 1cc/kg/hr mix 50u Reg Insulin in a 250ccNS = 1unit/5cc; start at 5cc/hr
At one hour: check BS then divide by 150 to set insulin drip rate If BS = 300; divide by 150 = 2; therefore insulin drip rate is 2u/hr or 10cc/hr Target BS = 120-180 Watch K+, as insulin shifts potassium into the cell Avoid LR, lactate converts to glucose; will see increase glucose levels 24-48hrs. after surgery Need at least two functioning IV access |
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Adrenalcortical dysfunction
Cushing’s |
glucocorticoid excess – either from endogenous oversecretion or chronic treatment of glucocorticoids (steroids) (DIFFICULT AIRWAYS)
Truncal obesity, thin skin, easy bruising |
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Adrenalcortical dysfunction
Addison’s Disease |
– Adrenalcortical insufficiency or withdrawal of steroids or suppression of synthesis
Hyperaldosteronism – excess of mineralocorticoid hormones Sometimes seen in excess of glucocorticoids |
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Adrenalcortical dysfunction
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Cause fluid and electrolyte disturbances
Fluid retention and hypertension Blood sugar elevation Continue glucocorticoid or mineralocorticoid replacement therapy |
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Liver dysfunction
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Coagulation dysfunction
Decrease albumin Cardiomyopathy Encephalopathy Varicies Decrease glucose, sodium, potassium Renal dysfunction |
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Giving glucose to a malnourished alcoholic without thiamine
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will cause irreversible brain damage!!!
THEY cannot metabolize the glucose and will cause irreversible brain damage |
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Liver dysfunction
goals |
Goal is to avoid making hepatic disease worse and increasing the chance of renal failure, coma, and death
Studies of portal hypertension have shown that mortality can be 50% when preop serum albumin = <3g/dL, serum bilirubin >3mg/dL, and ascites and encephalopathy are present NS can cause hyperchloremic acidosis!! If lots given… plasmalyte is the best (esp for liver tx) |
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Liver dysfunction
goals cont |
Maintain fluid balance/colloids
Monitor electrolytes; arterial pH should be maintained to avoid systemic metabolic alkalemia – noted to increase diffusion of ammonia through BBB worsening degree of encephalopathy RSI – especially if ascites present Preoxygenate Poor respiratory function; atelectasis Careful with sedatives, narcotics, and drugs metabolized by liver Low circulating protein/volume of distribution increased Evaluation of coagulation disorder Affects decision for regional vs GA; utilization of blood products intraop – FFP Avoid use of meds than may affect platelet function ASA / NSAIDs |
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Pheochromocytoma
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catecholamine secreting tumor of chromaffin tissue
Usually benign and localized in adrenal gland; 20 – 30% are malignant and are extra-adrenal Kidney removal (huge BP SPIKE-undx pheo) |
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Pheochromocytoma
Cardinal signs: |
Paroxysmal headache
HTN – orthostatic hypotension Sweating Palpitations/tachycardia |
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Pheochromocytoma
Anesthetic Considerations |
Adequate adrenergic blockade; then beta
Monitor volume status; cvp or swan; usually dehydrated Avoid drugs that stimulate SNS, inhibit PNS (pancuronium), or release antihistamine |
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Carcinoid Syndrome (releases kinin cascade)
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Tumors - 75% of the time originate in the GI tract – secrete serotonin (5-HT, 5-hydoxytryptamine) , histamine release, elevation of plasma kinins
7% of the pt with carcinoid tumors have carcinoid syndrome: Flushing Diarrhea Valvular heart disease Wheezing Vasodilation / vasoconstriction – (sometimes effects of 5-HT on heart - chronotropic, inotropic effect |
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CARCINOID SYNDROME TREATMENT
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Therapy of choice: somatostatin analog – powerful inhibitor of the release of peptides from carcinoid tumors and an inhibitor of the peptic effects on receptor cells
H2 blockers – combination tx H1/H2 (not H1 alone) Steroids Alpha adrenergic blockers Beta adrenergic blocker Vasopressin – for severe hypotension not responsive to somatostatin (will increase pulmonary vascular resistance) |
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Sickle cell
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– avoid hypoxemia, avoid vascular stasis, remain normothermic
Sickling causes patients to infarct body parts, they need to be warm and hydrated and stress of the body needs to be kept down. Even people with sickle cell trait they need to be taken care of lightly. |
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Usually dehydrated after dialysis
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watch with induction!
Prone to CHF, increase K+ levels, platelet dysfx, low HCT |
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Preserve renal function in pts with renal insufficiency
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Avoid frequent hemodynamic alterations – low CO, low renal blood flow
Acute renal failure is most likely to occur in pts who have renal insufficiency before surgery – greater if pt is >60years of age, and has left ventricular dysfunction. |
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Uremia
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– the end result of renal tubular failure
CV - cardiac failure Neuromuscular – neuropathy Metabolic / endocrinologic – electrolyte changes, acidosis Hematologic – anemia, coagulation and platelet dysfx Lowered immune system |
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Birth control pills and smoking
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have increased risk for blood clots
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Most teratogenic period
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3rd- 8th week during organogenesis
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BZD’s are linked to
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congenital anomalies
Cleft palate |
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All elective surgeries should be held until after delivery
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6 weeks later
Cannot be avoided, regional when possible and/or after first trimester |
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Muscular Dystrophy
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– unexpected effects to anesthetic drugs on myocardial function and skeletal muscle
Cardiac arrest & MH Sux avoided – hyperkalemia, rhabdomyolysis, cardiac arrest Increased risk of aspiration – degeneration of gastrointestinal smooth muscle |
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Osteoporosis
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Limited range of motion
Increased risk of fracture during positioning or movement to and from operating room table |
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. Loud murmur that radiates out of their neck
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they have aortic stenosis. (contra indication for a spinal)
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Size of tongue
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Large Tongue
Associated with acromegaly, cretinism, mongolism Hard to perform laryngoscopy, or mask ventilate |
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Mandibular hypoplasia (micrognathia)
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Associated with Pierre Robin
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Temporomandibular joint (TMJ) dysfunctio
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Degree of mouth opening
At least 4.0cm |
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Rheumatoid arthritis/Ankylosing spondylitis
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Restricts ROM of neck
Restricts vocal cord movement Tracheal stenosis |
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Thyromental Distance
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The distance, with the neck fully extended, between the thyroid notch and the lower Mandibular border
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Coma
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Uremia, hypoglycemia, hyperosmolar nonketotic, metabolic encephalopathy,
Lethargic – avoid drugs that might worsen Confusion / forgetful |
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Listen to heart sounds
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S3 – left ventricular failure
Jugular Vein Distention Carotid Bruits Peripheral Edema Exercise tolerance |
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BARREL CHEST
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late manifestation of obstructive lung disease
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GI/HEPATIC/RENAL/SKIN
INSPECT? |
Assess abdominal girth/ascites
Jaundice Bruising Tatoos Discoloration of skin – esp lower extremities |
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Rheumatoid Arthritis
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Atlantoaxial subluxation and odontoid fracture – causes spinal cord impingement – usually degree if impingement does not correlate with pts symptoms or lack of symptoms
Affects joints of larynx – limits vc movement and high incidence of erythema and edema associated with intubation Affects temporomandibular joint Positioning issues with these patients |
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The best way to screen for disease
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quality H & P
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CBC/Platelet function
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If expected to have large blood loss
Hx of renal disease, anemia, GI bleed, malignancies, bruising |
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Chemistry
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Diuretic use
Renal disease LFT’s for hepatic disease Diabetic |
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Coags
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Liver disease, blood thinners, malignancies
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EKG
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Goal is to establish baseline, pick up arrhythmias, blocks, ST changes, MI old or new; working pacemaker
Estimated ~30% of infarctions are silent with highest incidence in pts with diabetes and HTN The presence of q waves in a high risk pt, has increased perioperative risk and the possibility of active ischemia Influence anesthetic management and intraop monitoring Proceed to exercise or pharmacologic stress test |
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Protocol of group
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Men >45years, female >55years
Hx of CAD, MI, pulm disease, smoker, DM If big case Intrathoracic, major abdominal, big vascular case, lot of fluid shifting |
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CXR
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Detects tracheal stenosis, mediastinal or lung masses, edema, atelectasis, cardiomegaly, severe disease, i.e. hyperinflation
>60 or > 50 yrs if smoker Hx of pulm disease, malignancy, radiation therapy |
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PFT’s (for thoracic or sleep apnea pts)
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Purpose is to determine degree of pulmonary disease; determine response to bronchodilators & help plan lung resection
To decide whether the removal of lung tissue can be tolerated without compromising pulmonary function |
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Simplest & most informative
PFT’s |
FEV1 & VC
Flow volume loops Increased risk: FEV1 < 2L; FEV1:FVC < 15cc/kg or max breathing capacity is <50% of predicted value |
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Coronary Angiography – anatomic info
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Always for CABG/valve replacements
For noncardiac surgery – usually b/c +positive stress test |
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TEE/Echo – functional info (specific but not sensitive
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Determine ventricular dysfunction, regional wall motion abn, ventricular wall thickness, and valvular function
EF |
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PS-1
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Healthy patient
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PS-2
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Patient with mild systemic disease that results in no functional limitations
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PS-3
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Patient with severe systemic disease that results in functional limitations
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PS-4
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Patient with severe systemic disease that is a constant threat to life
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PS-5
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Moribund patient not expected to survive without operation
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PS-6
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Declared brain-dead patient for organ harvest
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Emergency (E
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Any patient for an emergency operation
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ASA 4E in most places
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likely a 5.
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Delaying/cancelling case
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Active URI
Newly “discovered” MI within last 6 months New unstable cardiac rhythm Coagulopathy Hypoxia Administrative issues Jehovah’s Witness patient Ethical procedure coverage Anesthesia provider coverage |
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Premedications
Sedation/anxiety |
Versed 1-2.5 mg IV
Ativan 0.5-2 mg IV/po Valium 2-10 mg IV/po Clonidine 0.1-0.3 mg p |
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Premedications
Antiemetics |
Ondansetron 4 mg IV
Dolasetron 12.5 mg IV Dexamethasone 4 mg IV (massive burning in the crotch) |
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Premedications
Anticholinergics |
Glycopyrrolate 0.1-0.2 mg IV
Don’t’ give glycopyrrolate in patients with asthma. |
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Pulmonary aspiration prophylax
Proton pump inhibitors (particulates) |
Omeprazole (Prilosec) 20 mg po night before surgery or > 2hours before
Pantoprazole (Protonix) 40 mg IV 20 min preop |
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Pulmonary aspiration prophylax
HISTAMINE (H2) ANTAGONISTS |
< 1 hour pre-op
Cimetidine (Tagamet) 200-400 mg po, IM, IV Ranitidine (Zantac)150-300 mg po/50-100 mg IV, IM |
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Pulmonary aspiration prophylax
Nonparticulate antac |
Bicitra 30-60 ml 30min preop
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Pulmonary aspiration prophylax
Metoclopramide (Reglan) (dopamine receptor antagonist) |
10 mg po/IV 1-2 hours preop
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Can not give particulates right before surgery
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Reglan also increases esophageal sphincter pressure makes it harder to reflux.
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