18 Feb Anesthesia Management for Autoimmune and MS Diseases (Exam 2) Flashcards
What is scleroderma also known as?
Systemic sclerosis.
What component is common in scleroderma and other diseases discussed?
Autoimmune component.
What are some diseases associated with autoimmune components?
- Lupus
- Fibromyalgia
- POTS
- Long COVID.
What is a significant concern regarding medication in patients with autoimmune diseases?
Polypharmacy.
What is a common symptom associated with lupus?
Lupus nephritis.
What skin symptoms are associated with scleroderma?
- Calcium deposits
- Raynaud’s phenomenon.
What is a common complication when measuring pulse oximetry in patients with Raynaud’s phenomenon?
Poor perfusion leading to inaccurate readings.
What are some alternative sites for pulse oximetry in patients with Raynaud’s phenomenon?
- Ear
- Nose
- Tongue.
What triggers Raynaud’s phenomenon?
Cold temperatures.
What is the recommended management for patients experiencing Raynaud’s phenomenon?
- Keep them warm
- Maintain perfusion.
- Consider digital block with lidocaine.
What is a common gastrointestinal risk for patients with scleroderma?
Reflux and aspiration.
What medication is recommended to manage reflux in scleroderma patients?
Pepcid.
What is the term used to describe the appearance of tight skin on hands in scleroderma?
Sclerodactyly.
What complication can arise from tight skin in scleroderma patients?
Difficulty in vascular access.
What are some neurological concerns in scleroderma patients?
- Radial neuropathy
- Ulnar neuropathy.
What cardiovascular complication is common in scleroderma?
Pulmonary hypertension.
What medication is preferred for induction in patients with pulmonary hypertension?
Tamsulosin.
What is a significant risk during the induction of anesthesia for patients with pulmonary hypertension?
Hypotension.
What should be monitored in patients with pulmonary hypertension during anesthesia?
Volume status.
What can be used to manage hypotension in patients with pulmonary hypertension?
Vasopressin.
What is a common symptom that can indicate pulmonary hypertension?
- Venous distention
- Barrel chest.
What should be done preoperatively to maximize the management of scleroderma patients? It’s actually quite a lot so pay attention.
PPIs
- Reflux
Calcium channel blockers
- Raynaud’s
ACEIs
- Renal protection: The only treatment that has been shown to alter the course of scleroderma is the use of ACE inhibitors to treat scleroderma renal crisis. which helped control the hypertension and improve the associated impaired renal function and effectively treat the 10% to 15% of patients who develop a scleroderma renal crisis.
Prostacyclins or phosphodiesterase inhibitors, oxygen, anticoagulation, and diuretics
- Pulmonary HTN
Digoxin
- Improve CO
Immunosuppressive and steroid therapy
- Targeted toward affected organ involvement
- Skin, lung, cardiac, and muscle
What is the acronym used to remember the symptoms of scleroderma?
CREST.
What can calcium channel blockers be used for in scleroderma patients?
Management of hypertension.
What is a common issue with ACE inhibitors and ARBs in the context of anesthesia?
Hypotension that is unresponsive to traditional therapies
What is the recommended approach for managing patients with pulmonary hypertension during induction?
Slow induction.
What is a potential complication of anesthesia in patients with existing pulmonary hypertension?
Inadequate oxygenation R/T decreased pulmonary compliance.
What should be done if a patient with scleroderma is suspected of having pulmonary hypertension?
Ideally, perform an echocardiogram. Avoid increasing PVR at all costs.
What are the common limitations in patients with scleroderma and rheumatoid arthritis?
Limited movement of mandibular tissues and neck mobility
These conditions often lead to difficulties in airway management.
What is atlanto occipital separation?
A serious condition where the connection between the skull and spine is disrupted
This can occur in patients with connective tissue disorders.
How can we prevent bleeding in patients with connective tissue disorders during surgery?
Avoid instrumenting the airway and use experienced personnel
These patients are at increased risk of bleeding.
What is TxA and how is it used?
Tranexamic acid, used to promote hemostasis in bleeding patients
Can be administered topically or intravenously.
What are some intravenous medications that can help with hemostasis?
TxA, Vitamin K, Calcium
These can be beneficial for patients at risk of bleeding.
What is the significance of vascular access in patients with connective tissue disorders?
Risk of vaso-occlusive crisis and difficulty due to friable skin
Caution is needed when placing arterial lines.
What are some methods to keep patients warm in the operating room? This is especially crucial for scleroderma patients.
Bear hugger, warming blankets, warm fluids, and increasing room temperature
Maintaining normothermia is crucial for patient safety.
What are the two types of VTE prophylaxis?
Chemical and mechanical
Examples include anticoagulants for chemical and SCDs for mechanical prophylaxis.
What is Duchenne muscular dystrophy?
A progressive muscle wasting disorder that typically starts in childhood
It primarily affects boys (presenting at 2-5yrs) and leads to severe disability.
What is the role of dystrophin in muscular dystrophy?
Dystrophin stabilizes muscle cell membranes
Its absence leads to muscle degradation.
What are common complications associated with Duchenne muscular dystrophy?
Pulmonary complications, scoliosis, UTIs, and rhabdomyolysis
These complications can arise due to muscle wasting and weakness.
What are the signs of mobility issues in children with muscular dystrophy?
Difficulty climbing, frequent falls, abnormal development patterns
These signs often become apparent in comparison to peers.
What cardiac issues can develop in patients with muscular dystrophy?
How about GI, and CNS?
Tachycardia and cardiomyopathy
- Regular echocardiograms are necessary to monitor heart health.
GI: Hypomotility, gastroparesis
CNS: Intellectual disability
What MS issues can develop in patients with muscular dystrophy?
Kyphoscoliosis, skeletal muscle atrophy, serum CK 20-100x normal
What effect does anesthesia have on patients with muscular dystrophy?
Increased risk of respiratory complications and need for careful sedation management
These patients often have weak cough and laryngeal reflexes.
What is the classic EKG pattern seen in muscular dystrophy patients?
- Short PR interval
- Sinus tachycardia
- V1 – tall R waves
- Limbleads –deep Q waves
These changes reflect underlying cardiac issues.
What is the importance of pre-warming patients in the operating room?
It’s easier to maintain warmth than to rewarm a patient
Pre-warming reduces the risk of hypothermia during surgery.
What are the risks associated with using neuromuscular blockers in patients with muscular dystrophy?
Potential for inadequate reversal and respiratory complications
Careful monitoring is required if neuromuscular blockers are used.
What should be avoided in patients with neuromuscular disorders?
Neuromuscular blockers
If neuromuscular blockers are used, ensure they are fully reversed before extubation!
Why might patients with neuromuscular disorders require post-intubation ventilator support?
They may have weak musculature requiring respiratory assistance
These patients often need specialized care in pediatric centers.
What is a common postoperative concern for patients with neuromuscular disorders?
Increased risk of aspiration
This can be managed with PPIs and gastric decompression techniques like NG tubes.
Why should succinylcholine be avoided in patients with neuromuscular disorders?
Risk of rhabdomyolysis, hyperkalemia, and/or cardiac arrest(VF or hyperkalemia)
- This patient population is at increased risk of malignant hyperthermia
Nondepolarizing muscle relaxants response is normal
Succinylcholine can exacerbate muscle weakness in these patients.
What are the preferred sedatives for pediatric patients with neuromuscular disorders?
Ketamine and precedex
Ketamine is effective for short-term sedation in children.
What is Myasthenia Gravis?
A chronic autoimmune disease characterized by muscle weakness D/T decreased functional post-synaptic AChreceptors.
- Partial recovery obtained with rest.
- ACh receptor-bindingantibodies andthymusabnormalities
It often presents in cycles of exacerbation and remission.
What are the differences between type 1 and type 4 MG?
- Type I – Limited to involvement of the extraocular muscles
- Type IV – Severe form of skeletal muscle weakness
Progression from Type I or II
What are common symptoms of Myasthenia Gravis?
How about other symptoms?
- Ptosis, diplopia, dysphagia, and muscle weakness
- Dysarthria and difficulty handling saliva
- Isolated respiratory failure
- Arm, leg, or trunk muscle weakness
- Myocarditis
What is a Myasthenic crisis?
A severe exacerbation of Myasthenia Gravis leading to respiratory failure and is often triggered by missed medications or increased activity.
- Can also occur D/T drug resistance
What is the difference between a Myasthenic crisis and a Cholinergic crisis?
Myasthenic crisis improves with edrophonium, while Cholinergic crisis worsens
SLUDGE-M Symptoms
Edrophonium is used diagnostically to differentiate between the two.
What is the first-line treatment for Myasthenia Gravis?
Neostigmine
It is used to reverse neuromuscular blockers but may require higher doses in patients with tolerance.
What surgical intervention may be beneficial for Myasthenia Gravis patients?
Thymectomy
This can lead to remission and reduce the need for immunosuppressants.
What type of medications should be approached with caution in Myasthenia Gravis patients? These can still help.
Corticosteroids and immunotherapy agents
- Immunosuppressionwith Corticosteroids, azathioprine, cyclosporine,mycophenolate indicated when skeletal muscle weakness is notadequately controlled by anticholinesterase drugs
- Plasmapheresis – short-term clinical improvement inmyasthenic crisis or preparation for thymectomy(Removes antibodies from circulation)
- Immunoglobulin –short-term clinical improvement inmyasthenic crisis or preparation for thymectomy(Temporary effect) but has no effect on circulatingconcentrations ofAChreceptor antibodies
These medications can exacerbate symptoms or induce crises.
What are the potential triggers for a crisis in Myasthenia Gravis patients?
Stress, missed medications, and infections
Stressful situations, such as accidents, can precipitate a crisis.
What are the symptoms of cholinergic crisis?
SLUDGE-M
- Salivation
- Lacrimation
- Urination
- Defication(Diarrhea)
- GI Upset
- Emesis
- Miosis
These symptoms may arise from excessive cholinergic medication.
What is the significance of the thymus in Myasthenia Gravis?
The thymus can be involved in the autoimmune process
Thymectomy may help reduce symptoms in patients with Myasthenia Gravis.
What are the potential complications of neuromuscular blockers in Myasthenia Gravis patients?
Increased tolerance and ineffective reversal
Patients may require alternative methods to manage muscle tone.
What is a potential alternative to succinylcholine in patients with contraindications?
Remifentanil.
What condition is characterized by a chronic degenerative process affecting articular cartilage?
Osteoarthritis.
In which joints is osteoarthritis most commonly observed?
- Hips * Shoulders * Fingers * Ankles
What is a major cause of osteoarthritis?
Repetitive biomechanical stress.
How does obesity contribute to osteoarthritis?
It leads to chronic overuse due to excess weight.
What can be a result of steroid injections for osteoarthritis?
Joint failure may occur faster.
What is the typical treatment approach for osteoarthritis?
- Exercise * Physical therapy * NSAIDs * TENS unit * Acupuncture
What is the common symptom pattern for patients with osteoarthritis?
Pain that decreases with rest.
What type of arthritis is characterized by autoimmune-mediated inflammation?
Rheumatoid arthritis.
What is a common symptom of rheumatoid arthritis in the morning?
Increased stiffness and pain.
What can happen to the TMJ in patients with rheumatoid arthritis?
It may become inflamed and painful.
What joints can rheumatoid arthritis affect?
It can affect almost every joint in the body except the except t-spine and lumbosacral spine
What is the significance of the atlantoaxial joint in patients with rheumatoid arthritis?
Atlantoaxial Subluxation can occur due to inflammation.
Fill in the blank: Osteoarthritis is most commonly seen in _______.
The hips and shoulders.
True or False: Patients with rheumatoid arthritis typically feel better in the morning.
False.
What is one of the main challenges for patients with osteoarthritis when trying to lose weight?
Joint pain that limits exercise.
What type of joint injection is often used to treat osteoarthritis pain?
Steroid injections.
What are examples of regenerative therapy mentioned for joint health?
- Stem cell therapy
- Platelet-rich plasma injections
- Prolotherapy
What is a common result of disc pressure on nerves in the lumbar region?
Pain that radiates down the leg.
What are some common treatments for managing rheumatoid arthritis symptoms?
- Immunosuppressants * Physical therapy * Warm compresses
What is the number one thing that pops up on tests related to MSK issues?
Atlantoaxial subluxation
Atlantoaxial subluxation is a common issue in patients with certain conditions that can lead to significant complications.
What symptoms may occur in patients with acute atlantoaxial instability?
Hoarseness, difficulty breathing, frontal neck pain
These symptoms can indicate significant underlying issues and may require careful monitoring.
What anatomical structure is at risk when the odontoid process protrudes into the foramen magnum?
Spinal cord
What are potential outcomes of pressure on the vertebral arteries due to atlantoaxial instability?
Altered flow, stroke-like symptoms
What are acute symptoms associated with cricoarytenoid arthritis? Chronic symptoms?
Acute – hoarseness, dyspnea, and stridor w/ tenderness over the larynx; swelling and redness of arytenoids
Chronic – asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction
These symptoms can complicate airway management and intubation.
What is a major concern after intubating a patient with cricoarytenoid arthritis?
Vocal cord injury
What common conditions are associated with patients who have atlantoaxial instability?
Osteoporosis, weakened skeletal muscles, peripheral neuropathies
What is a common cause of atlantoaxial instability?
Abnormalities in the bones, vertebral fractures, bone tumors
What condition can lead to atlantoaxial instability in individuals with Down syndrome?
Abnormal protein in connective tissue
What can cause pathological changes in the first or second cervical vertebrae?
Steroid injections into the neck
What pulmonary condition may develop in patients with rheumatoid arthritis?
Restrictive lung disease, rheumatoid nodules
What is a hematologic concern for patients with rheumatoid arthritis?
Anemia, neutropenia, high platelet counts
What is the risk associated with high platelet counts in rheumatoid arthritis patients?
Increased risk of clotting
What ocular manifestation might be seen in patients with rheumatoid arthritis?
Keratin deposits in the conjunctiva
What is the first-line disease-modifying anti-rheumatic drug (DMARD) for rheumatoid arthritis?
Methotrexate
What are tumor necrosis factor inhibitors used for?
To treat rheumatoid arthritis when DMARDs are ineffective
What is a common symptom in lupus patients during pregnancy?
Pregnancy-induced hypertension (PIH)
What rash is commonly associated with lupus?
Butterfly rash
- Bonus points if you said maculopapular rash :)
Don’t forget about the discoidlupuslesions, which are thick and disk-shaped.
- They often appear on the scalp or face and can cause permanent scarring.
- They may be red and scaly, but they do not cause pain or itching.
What is a common complication in lupus patients related to the lungs?
Lupus pneumonia
What imaging finding may indicate vanishing lung syndrome in lupus patients?
Diaphragm elevation on chest X-ray
Vanishing lung (recurrent atelectasis; diaphragmatic weakness or phrenic neuropathy)
What is a common initial treatment for lupus patients? Why?
NSAIDs or aspirin
- To treat arthritis and serositis
What are some other treatments for SLE?
- Anti-malarial – dermatologic and arthritic manifestations
- Corticosteroids – tx for severe symptoms; thrombocytopenia and anemia (Suppresses glomerulonephritis and CV abnormalities effectively but is a major cause of morbidity)
- Immunosuppressants – better alternative than high-dose steroids (methotrexate, azathioprine)
Death during the course of SLE may be due to coronary atherosclerosis. The development and progression of coronary atherosclerosis is accelerated by treatment with corticosteroids.
What type of anemia is commonly associated with lupus?
Hemolytic anemia
How do you manage the risk of nerve injury during thyroid surgery in lupus patients?
Use of a neuro interventional monitoring tube (NIM tube)
What is malignant hyperthermia?
A hypermetabolic syndrome triggered by certain anesthetic agents
What are the signs of malignant hyperthermia?
What’s usually the first sign?
What can trigger malignant hyperthermia?
Succinylcholine, volatile anesthetics
50% Mortality risk
What causes malignant hyperthermia?
Genetic mutation
This mutation can lead to a hypermetabolic state in response to certain anesthetic agents.
What is the mortality rate associated with malignant hyperthermia?
Around 50% (Extremely high)
The exact rate can vary, but it is significantly high without prompt treatment.
What is a key treatment for malignant hyperthermia? What are the doses?
Dantrolene
- 20 mg + 3 G mannitol (help with UOP)
- Mix with 60 mL sterile water
- Initial dose 2.5 mg/kg
Max upper limit 10 mg/kg
- Dantrolene is an effective treatment for MH because it reduces the concentration of sarcoplasmic Ca2+to below contractile threshold.
- Dantrolene’s ability to suppress Ca2+release from SR appears to depend on elevated sarcoplasmic Mg2+concentration
True or False: Nitrous oxide is safe to use in patients with malignant hyperthermia.
True
Nitrous oxide is not classified as a volatile agent and is considered safe.
Fill in the blank: Early symptoms of malignant hyperthermia include _______. (2)
Hypercarbia and Masseter muscle spasm
This can lead to difficulties in intubation and ventilation.
What happens to CO2 levels in patients with malignant hyperthermia?
They elevate
Elevated CO2 levels indicate inadequate ventilation and can signify worsening respiratory status.
What are the systemic effects of malignant hyperthermia?
Acidosis and hyperkalemia
These conditions arise due to muscle breakdown and metabolic disturbances.
What should be done first when treating a patient with malignant hyperthermia?
Discontinue all volatile agents
Stopping the triggering agents is crucial for effective management.
What is the initial dose of dantrolene for treating malignant hyperthermia?
2.5 mg/kg
This dose may be repeated, with a maximum total dose of 10 mg/kg.
What are some supportive treatments for malignant hyperthermia?
Bicarbonate, calcium, insulin, albuterol
These treatments help manage acidosis and hyperkalemia.
What is one method used to cool patients experiencing malignant hyperthermia?
Cold IV fluids
Administering cool fluids helps lower body temperature in these patients.
What electrolyte should be monitored in patients after a malignant hyperthermia crisis?
Potassium levels
Elevated potassium can lead to serious cardiac complications.
What is the purpose of a muscle biopsy in suspected malignant hyperthermia cases?
To evaluate for genetic predisposition
Muscle biopsies are done to test for abnormal reactions to anesthetic agents.
Fill in the blank: Malignant hyperthermia is often triggered by _______.
Volatile anesthetic agents and Succs
Avoiding these agents is crucial in patients with a known history of MH.
What is the role of the malignant hyperthermia registry? MHAUS.ORG
To collect data on MH cases
This registry helps track cases and improve understanding of the condition.
What is a significant risk for patients with malignant hyperthermia if not treated promptly?
Cardiovascular collapse
This can occur due to severe metabolic and electrolyte imbalances.
Why is it important to ventilate patients with malignant hyperthermia with 100% oxygen?
To flush out volatile agents
Hyperventilation with pure oxygen helps remove anesthetic agents from the body.
What is a major concern when administering mannitol?
Dehydration
Administering mannitol while trying to flush out the kidneys can lead to dehydration.
How much mannitol can a patient potentially receive during MH crisis?
50 to 100 grams
- Ensure the patient’s UOP is being monitored and they are receiving adequate fluid therapy to compensate for losses.
This occurs when multiple vials are administered.
What is soda lime used for in anesthesia?
To absorb CO2
Soda lime is utilized in a closed system to remove carbon dioxide during rebreathing.
True or False: Soda lime is changed after every use.
False
Soda lime is used until it is exhausted and not changed every case.
What actions are taken to prepare an anesthesia machine for a MH susceptible case?
Change soda lime, remove vaporizers, flush with oxygen
- Ideally you’d receive an entirely new machine from biomed but that isn’t realistic.
What can happen if soda lime is not changed regularly?
Rebreathing of volatile agents
Exhausted soda lime can absorb volatile agents, leading to potential rebreathing.
