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EDRA > 6.4 Systemic disease > Flashcards

6.4 Systemic disease Flashcards

1
Q

Lumbar epidural anaesthesia affect muscles

A

Lumbar epidural anaesthesia

paralyses the abdominal and intercostal muscles

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2
Q

Respiratory parameter are affected in lumbar

A

Therefore the
effort-dependent respiratory parameters are affected:

FEV1 (forced expiratory volume in the first second),

FVC (forced vital capacity)

PEFR (peak expiratory flow rate)

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3
Q

Respiratory parameter unaffected in lumbar epi

A 
Other respiratory parameters are unchanged:
tidal volume, 
minute ventilation, 
respiratory rate, 
closing capacity 
FRC (functional residual capacity).
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4
Q

Brachial plexus blocks affect on respiratory

A

supraclavicular, infraclavicular, interscalene

may paralyze the diaphragm

thereby reduce FEV1 and FVC.

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5
Q

Axillary affect on respiration

A

Axillary block has no effect on diaphragm and therefore on any
respiratory parameter

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6
Q

Pulmonary function preservation post thoracotomy is better with what block

A

Various studies have shown that

after thoracotomy,

preservation of pulmonary function
is better with paravertebral blockade than
epidural or intercostal blockade

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7
Q

chronic renal disease

Affect of spinal and thoracic anaesthesia on RBF

what level is it affected

A

renal blood flow
is not affected
by spinal and
lower-thoracic anaesthesia.

However,
higher thoracic blocks up to
T1 have decreased renal
blood flow in various studies

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8
Q

Graft function in renal transplant patients affect by GA or Neuraxial

A 
Graft function in renal transplant patients 
is not affected by 
either
general anaesthesia or 
central neuraxial anaesthesia
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9
Q

uremic patients affect on circulation

how does this affect absorption following PNB

A

hyperdynamic circulation,

resulting in increased
absorption of local anaesthetic
following peripheral
nerve blockade.

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10
Q

In uremic patients,

pH changes affect on LA

A

Acidosis increases the
free fraction of local anaesthetic

like bupivacaine by
decreasing protein binding

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11
Q

What counters the pH changes in Uremic patients

A

However, uremic patients have
increase in levels of α1-acid glycoprotein,

resulting in increase in
protein binding and
decreasing volume of distribution

Thus these two opposing effects try to balance
each other, but the effect of acidosis predominates

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12
Q

Does any method of anaesthesia help with AV fistula

GA v RA

A

Creation of arteriovenous fistula
is one of the

commonest surgeries in
patients with chronic renal failure.

Various studies have shown that there is

increased blood flow through
fistula following brachial plexus block or
general anaesthesia.

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13
Q

Does any method of anaesthesia help with AV fistula

Local infiltration

A

Local anaesthetic infiltration
has not shown similar
increase in blood flow
through the fistula.

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14
Q

Does any of method of anaesthesia improve outcome

A

The final outcome has remained
almost the same,
independent of the type of anaesthesia

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15
Q

Hepatic extraction ratios

high

A

Local anaesthetics depending on
hepatic blood flow for their clearance
are said to have high hepatic extraction ratio
(e.g. etidocaine).

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16
Q

Hepatic extraction ratios

Low

A 
Local anaesthetics depending on 
hepatic enzymatic activity for their
clearance are said to have 
low hepatic extraction ratio
 (e.g.  bupivacaine).
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17
Q

Hepatic extraction ratios

A

Lignocaine is dependent on
both hepatic blood flow and enzymatic
activity and has intermediate
hepatic extraction ratio.

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18
Q

regional anaesthesia in patients
with hepatic disease
severe - how are mechanisms affected

A

In patients with severe hepatic disease, both mechanisms of clearance are
affected and therefore the clearance of local anaesthetics is reduced

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19
Q

Does dose need to be changed for single shot

A

plasma levels do not differ after a
single dose of local anaesthetics due to
altered volume of distribution.

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20
Q

LAST with continious?

A

However, there is possibility of local
anaesthetic toxicity with
continuous infusions, and
doses must be reduced.

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21
Q

Liver blood supply

is there autoregulation present?

A

Liver has dual blood supply:

hepatic artery (25%) 
and 
portal system (75%).

Autoregulation is present in

hepatic arterial system,

but not in portal venous system

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22
Q

hepatic arterial buffer response

A

Hepatic artery alters its blood supply
depending upon portal venous
blood flow.

This is called hepatic arterial buffer response.

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23
Q

high level of neuraxial block

A

A high level of
neuraxial block is associated

with decrease in the portal blood flow,

but hepatic arterial blood flow is maintained

24
Q

Diabetic patients Nerve stimulator

A 
Diabetic patients usually have 
peripheral neuropathy and require
higher stimulating current to 
locate nerves via nerve stimulator
during peripheral nerve blockade.
25
Q

Is there any affect on glucose control and outcome

A

Tight glucose control perioperatively is associated with improved
outcome in diabetic patients

26
Q

Does RA Affect glucose levels at all?

A

Regional anaesthesia
prevents hyperglycaemic response

to surgery by various mechanisms:

inhibiting gluconeogenesis,

inhibiting catecholamine
and cortisol secretion
(prevents stress response to surgery).

27
Q

regional anaesthesia in patients
with hypothyroidism

Any change to nerve

A

Thyroid neuropathy is common in hypothyroidism.

It is characterised by a delay in
conduction velocity on testing.

28
Q

regional anaesthesia in patients
with hypothyroidism

Nerve stimulation difference?

A

Higher intensity of stimulating current
may be required to locate the
nerves via nerve stimulator during
peripheral nerve blockade.

29
Q

Does hypothyroidism lead to any nerve deficits

A

Nerve entrapment is common –
median nerve (carpal tunnel syndrome)
and CNVIII involvement (deafness).

30
Q

Double crush syndrome

A

There is increased risk of injury to nerves at one site if they are compressed or damaged at a different site.

Therefore, hypothyroid patients
with neuropathy are at higher risk of
neurological damage
following regional anaesthesia.

Trivial trauma with the needle during
block in patients can lead to
neurological deficits: this is called ‘double
crush syndrome’.

31
Q

How can thyroid neuropathy be corrected?

A

Thyroxine helps in prompt
correction of neuropathy, thereby reducing
the risk of neurological injury.

32
Q

most common injuries reported from anaesthesia are in the following order

A

Ulnar nerve injury >
brachial plexus injury >
lumbosacral nerve roots >
spinal cord.

33
Q

Incidence of BP & Ulnar Nerve injury

> with GA vs Regional which?

A

Incidence of brachial plexus and ulnar nerve injury is more with general anaesthesia than with regional anaesthesia

34
Q

Causes of neurological injury

A

In the majority of cases,
the cause of neurological injury is

ischaemia,

prolonged tourniquet time,

stretch,

direct trauma and haematoma
compressing nerve or interfering with its
blood supply

35
Q

Mononeuropathy - whats safe

A

In patients with mononeuropathy,
both regional and general
anaesthesia are safe.

36
Q

Parkinsonism is characterised

A

Parkinsonism is characterised by loss of
dopaminergic neurons in
substantia nigra

clinically manifesting
as tremor,
rigidity and
bradykinesia.

37
Q

General anaesthesia & Parkinsonism

A

1
inhalational agents –
may accelerate autonomic instability

2
muscle relaxants, controlled ventilation –.
prolong post-operative ventilator support

3
opioids –
 exacerbate muscle rigidity,
 post-operative 
nausea and vomiting

4
increased incidence of post-operative cognitive dysfunction

38
Q

Regional anaesthesia offers for parkinsonism

A

Regional anaesthesia offers:

better control of autonomic instability

avoidance of inhalation agents and muscle relaxants

less impairment of respiratory function.

Therefore, regional anaesthesia is always preferred over general
anaesthesia where feasible.

39
Q

Multiple sclerosis (MS) what nerves affect

A 
Multiple sclerosis (MS): 
involves only central nervous system

(brain and spinal cord)

and not the PNS.

It is associated with demyelination
in brain and spinal cord

40
Q

MS
LP block
PVB

A

Lumbar plexus blocks and paravertebral blocks
may have a prolonged
duration of action due to
subarachnoid or epidural spread.

41
Q

MS & PNB

A

Peripheral nerve block is safer where feasible.

42
Q

MS & surgery

A

Patients with multiple sclerosis may
have a relapse
due to stress of surgery,
irrespective of type of anaesthesia they receive

43
Q

Spinal shock

A

Acute spinal cord injury is associated with spinal shock.
There are four phases of spinal shock:

Stage 1: areflexia (0–1 days)
Stage 2: return of reflexes (1–3 days)
Stage 3: hyperreflexia (initial) (1–4 weeks)
Stage 4: hyperreflexia, spasticity (1–12 months

44
Q

SCord injury acute phase ra vs ga

A

In the acute phase of spinal cord injury,
general anaesthesia is preferred because of:

1
the risk of airway compromise

2
haemodynamic instability
(relative contraindication for
regional anaesthesia)

3
the need for deep-vein thrombosis prophylaxis,
as there is a high risk
of thromoembolism.

45
Q

Caution in GA ~>24h

A

However, succinylcholine use may
lead to hyperkalaemia if used after 24
hours,

because of proliferation of
extrajunctional nicotinic acetylcholine
receptors.

46
Q

Chronic phase SC injury RA vs GA

A

chronic phase of spinal cord injury,
regional anaesthesia is
preferred because:

Autonomic dysreflexia is seen
after the resolution of acute phase of
spinal cord injury.

47
Q

Autonomic dyreflexia @what level

what is it

A

It is seen when the level of injury is at or above
T7.

It is characterised by
extreme haemodynamic instability from
cutaneous or visceral
stimulation below the level of spinal cord injury.

48
Q

Why is RA preferred in chronic injury

A

If the injury is below T7, the risk of autonomic dysreflexia is reduced.
Regional anaesthesia may be
used in chronic spinal cord injury, as it
prevents autonomic dysreflexia.

49
Q

Myasthenia gravis is

A

Myasthenia gravis is an
autoimmune disease
characterised by weakness
and progressive fatiguability.

50
Q

Myasthenia gravis

pathophys

A

There are antibodies against the
α-subunit of nicotinic ACh receptors
at neuromuscular junct

51
Q

Myasthenia Gravis

Medical treatment

A

Medical treatment
includes

anticholinesterases,

steroids and

immunosuppressants
like cyclosporine, azathioprine,

plasmapheresis and
immunoglobulin

52
Q

Surgical treatment

Myasthenia Gravis

A

Surgical treatment includes

thymectomy,
which can be done under
general anaesthesia or
thoracic epidural anaesthesia.

53
Q

Quirk of Rx that must be checked before a form of anaesthesia MG

A

Full coagulation profile must be
obtained prior to regional anaesthesia,
as platelet function might be affected by steroids and
immunosuppressants

54
Q

Is supraclav safe in MG

A

Bulbar and respiratory muscles
may be affected in myasthenic patients
hence supraclavicular blocks should be avoided.

55
Q

Are all LA safe in MG?

A

Metabolism of ester local anaesthetics
is dependent on cholinesterase activity,
and therefore they are best avoided.

56
Q

MG and opioids

A

Myasthenic patients have
increased sensitivity to opioids and
sedatives, and so these
should be used in low doses.

EDRA (26 decks)

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