Anesthesia and Musculoskeletal Diseases Flashcards

Question

What are treatment options for rheumatoid arthritis?

Answer 1

* **Drugs to treat inflammation/pain** * ASA * NSAIDS * chronic nsaid use might affect coagulation * corticosteroids (acute periods only) * **DMARDS**- alter immune response and slow disease progression. **DO NOT GIVE DMARD WITH NSAID** * methotrexate\< **check LFT/CBC** * azathioprine * antimalrial drugs * minocyclin * TNF inhibitors/MAD * **SX treatment** * relieve pain and restore joint funciton * tendon release procedure, synovectomy, joint replacmenet

Answer 2

* Document preop ROM limits, baseline symptoms of pain, numbness, weakness * consider awake fiberoptic intubation * TMJ- * assess mouth opening * may be limids * TMJ with cervical spine immobility may limit DL visualization * Cricoarytenoid joints * fixation may present as voice changes or hoarseness * arthritis and inflammation can make glottic opening difficult to ID or stenotic * cricoarytenoid joint arthritis requiring decreased tube size * minimal edema may lead to airway obstruction postoperatively * Atlantoaxial instability

Answer 3

* Atlantoaxial subluxation (AAS) * distance between ant arch of atlas to odontoid process \>3mm on radiologic imaging (during neck extension) * occurs in 25% severe RA patients * risk of cervical spinal cord/medulla compression by odontoid process and interference with vertebral artery blood flow * **determine head positions AWAKE that can be tolerated** * **enquire about tingling of hands/feet, pain and assess ROM** * **AVOID EXCESSIVE MOVEMENT DURIGN LARYNGOSOCPY**

Answer 4

* Anemia of chronic disease * effect of meds on PLT function * with lung DX * PFT/intraop ABG/post op vent support * may need corticosteroids * extubate with caution in those with cricoarytenoid arthritis

Answer 5

* commonly referred to as degenerative joint disease (DJD)"wear and tear" * Hallmark is degerneration of articular cartilage * most commonly hip/knee * **differ from RA in that there is minimal inflammatory reaction** * typically in middle/lower cervical and lower lumbar * associated protrustion of nucleus pulposus resulting in nerve root compression * occurs in weight bearing joints or conditions that put undue stress on joint * obesity * joint deformity

Answer 6

* positioning * support affected joints * position to minimize risk of injury * drugs used in treatment * corticosteroids not recommended * NSAIDS and ASA * potential bleeding issues

Answer 7

* Bone cement (polymethylmethacrylate or PMMA) * "cement" is a misnomer, not bonding two things together * Bone cement implantation syndrome (fat and marrow embolisms) * hypoxia (increased pulm shunt * hypotension * dysrhythmia * pulm hypertension * decreased CO

Answer 8

* Provides a bloodless field that greatly facilitates surgery * inflation pressure usually aboug 100 mmHg over systolic blood pressure * prolonged inflation \>2h, pain, nerve damage * be careful not to over administer opioids for touniquet pain! * *better to admin esmolol to temporarily decrease BP* * Deflation * hemodynamic changes * washout of accumulated metabolic wastes * can cause drop in BP

Answer 9

Autoimmune destruction of postsynaptic acetylcholine receptors at NMJ (up to 80% loss) * characterized by weakness and rapid exhaustion of skeletal muscle * particularly those innervated by cranial nerves (ocular, pharyngeal and laryngeal) * course marked by exacerbations & remissions * 1:7500 (women 20-30 and men \>60 yo) * sx, infection, stress and pregnancy lead to exacerbations * association with thrmic hyperplasia and thymoma

Answer 10

* Mild to severe weakness * Class I = mild * class IV= severe * ocular muscle most commonly affected * ptosis, dysphagia, and diplopia (most common initial complains) * Bulbar involvement/laryngeal and pharyngeal muscle weakness * difficulty clearing secretions * pulm aspiraiton * myocarditis possible * afib, heart block, CMP * Severe dx associated with asymmetrical proximal muscle weakeness (no atrophy though) * neck, shoulder, respiratory muscles affected

Answer 11

* Usually oral anticholinesterase with or without steroid therapy * **Cholinesterase** **inhbiitors** (PO Pyridostigmine) * onset 30 min, peak 2 hours, DOA 3-6 HR * Higher dose can paradoxically enhance muscle weakeness= "cholinergic criss" * **Corticosteroids**- prednisone limits antibody production (second line therapy after failure of above) * Thymectomy- sx approach * can be cure for some pts * median sternotomy or mediastinoscopy * Plasmapheresis- removes antibodies during crisis (temporary) * depletes plasma esterase levels * prolonged effect of succ, mivacurium, ester linked LA etc

Answer 12

* Elective surgery only during remission * premedication/opioids minimized or avoided * prone to weakness * aminoglycoside antibiotics can enhance weakness * **Induction** * ****short acting agents (ie prop) * consider intubation without muscle paralysis * intubation with deep volatile agent may be sufficient\<-- synergistic effects with MR * topical lidocaine application to airway * if using NDMB, should use PNS at obicularis oculi (may overestimate block) * Aspiration risk- consier RSI * may need higher does succinylcholine (2mg/kg) to overcome resistance, but prolonged effect should be anticipated * if succinylcholine is used- do not use NDMR until muscle function has returned--\> phase II block

Answer 13

* Maintenance * deep anesthesia with volatile agent can provide sufficient relaxation for many surgical procedures * Emergence * at great risk for postop respiratory failure * advise patient may awaken with ETT in place * careful evaluation of vent function prior to extubation * close observation in recovery

Answer 14

* Referred to as Lambert-Eaton myasthenic syndrome (LEMS) * presents with proximal muscle weakeness * develops in association wiht a neoplasm, but also seen with other ocult malignancies or idiopathic autoimmune * **usually small cell carcinoma of lung** * Disorder results form **presynaptic** side defect of NM transmsission * **IgG** antibodies form agianst presynaptic voltage gate calcium channel * decreased release of ACh * If tumor present, these antibodies are directed at the tumor but cross-react with calcium channels * when tumor resolves, symptoms resolve

Answer 15

* Proximal muscle weakness (most central muscles) * typically begin with lower extremities, spreads ot upper limbs, bulbar, respriatory muscles * change in gait, ability to stand, climb stairs * exercise improves strength * Autonomic dysfunction very common * hemodynamic instability * dry mouth * urinary hesitancy

Answer 16

* May be undiagnosed. suspect in bronc, mediastinosocpy, thoracoscopy for suspected lung Ca * unlike myasthenia gravis, LEMS pts are very sensitive to both depolarizing and nondepolarizing NM blocker * AChe drugs not helpful in these disease and may not effectively reverse clinical effects of NDMR * Volatile agnets alone often sufficient to provide muscle relaxation for both inbuation and surgical procedures * NMBAs should only be givne in small increments and with careful NM monitoring

Answer 17

**MYASTHENIC SYNDROME** * Manifestations- proximal limb weakenss (legs more than arms), exercise improves strength, muscle pain common, reflexes absent/decreased * **Gender-** affects male more htan femlas * **Co-exist condition: small cell lung Ca** * **Response to muscle relaxants** * ****sensitive to sucicnylcholine AND non depolarizing MR * Poor response anticholinesterases **MYASTHENIA GRAVIS** * **Manifestations**- extraocular, bulbar and facial muscle weakness; exercise causes fatigue; muscle pain unommon * **Gender:** affects females more often than males * **Co-existing patho conditon-** thymoma * **Reponse to MR-** * **resistant** to succinylcholine (need more! up to 2mg/kg) * **sensitive** to nondepolarizing MR * **Good** response to anticholinesterases

Answer 18

* A range of congenital muscular disorders characterized by progressive weakness and degeneration of muscle * affected individuals produce abnormal dystrophin * protein found on sarcolemma of muscle fibers * **increased permeability of skeletal muscle precedes symptoms** * Painless degeneraiton * atrophy of skeletal muscle * Classified according to inheritane * x-linked: Duchenne's (psudohypertrophic) and Becker * most common * autosomal recessive: limb-girdle, congenital * autosomal dominant: facioscapulohumeral, oculopharyngeal

Answer 19

* Duchenne's (pseudohypertrophic) * ALmost exclusively male * incidence 1-3 per 10,000 live male births * presents between 2-5 yo * Characterized by symmetric proximal muscle weakness manifesting in gait disturbance * pelvic girdle * psudohypertrophic- fatty infiltration * Kyphoscoliosis results form progressiv eweakness and contractures * muscle weakness pronoucnced in proximal extremities * wheelchair by age 8-10 * fatal by 20 yo

Answer 20

* Degeneration of cardiac muscle- *may see cardiopulmonary depresison with volatile anesthetics* * ECG abnormalities * atrial arrhythmias * prolonged PR interval * Decreased myocardial contractility and CMP * Mitral regurg secondary to papillary muscle dysfunction

Answer 21

* Chonic weakness of inspiratory muscles * decreased ability to cough and clear secretions * Frequent **pulmonary infections** * ***anticipate post op pulmonary dysfunction*** * **kyphoscoliosis** and muscle degernation lead ot severe restrictive disease pattern * **sleep apne**a is common * **pulmonary hypertension** with disease progression

Answer 22

* Muscle weakness, cardiac and pulm involvement * preop sedation/opioids best avoided * resp muscle and laryngela reflex weakness * gastric hypomotility * aspiration prophylaxis * antacid with H2 blocker or PPI * Prokinetic like reglan to reduce volume * antisialogogue like glyco if secretions are an issue * Positioning can be complicated by kyphoscoliosis and flexion contractures

Answer 23

* Succinylcholine contraindicated * risk of inducing severe hyperkalemia, rhabdomyolysis, v fib and cardiac arrest * malignant hyperthemia risk

Answer 24

* Marked cardiopulmonary depression may be seen with voltaile anesthetics * normal to prolonged resposne to NDMR * Anticipate post op pulm dysfunction * Regional anesthesia may be preferable

Answer 25

* Multi system disorder of the connective itssue caused by mutations in extracellular matrix protein fibrillin 1 * classic marfan's syndrome occurs in about 4-6 our of 100,000 people * involve cv, skeletal and ocular systems * classic manifestations include proximal aortic aneurysm, dislocation of ocular lengs and long-bone overgrowth * *need to see recent echo, cardiac workup*

Answer 26

* Aortic aneurysm and dissection remain most life-threatening manifestations (increased risk in pregnancy) * Cardiac valve prolapse/dysfunction/regurg * mitral valve * aortic valve- incompetence often related to dilation of ascending aorta * arrhythmia- BBB * aortic and atrioventricular valves prone to calcification

Answer 27

* High incidence pneumothorax * spinal/sternal deformities can lead to restrictive lung disease

Answer 28

* Dislocation of ocular lengs * Retinal detachment

Answer 29

* Beta blockers is standard of care * reduce workload of heart * delay/prevention aortic aneurysm and dissection * Surgical procedures * elective aoritc repair * may electively repair aortic root when \>4.5 cm * spinal fusion for scoliosis * *may be prone and that increases risk of ocular dislocation*

Answer 30

* Preop assessment should concentrate on cardiac abnormalities * airway evaluation and management * high arched palate with crowded teeth * visualization of the laryngx during direct larngosocpy rarely difficult * TMJ dislocation * tendency for join laxity * avoid extreme movement of mandible * Tracheomalacia * floppy tracheal cartilage leading to tracheal collapse * Beta blockade- should b econtinued perioperativley * Continuous monitor for pneumothorax!

Answer 31

hemodynamic stability! * Prevent sudden increase in myocardial contractility * this produces an increase in aortic wall tension * Avoid excessiv eendogenous catecholamine production * control pain/anxiety * hemodynamic stable inudction should be performed * Treat hypertensive episodes immediately * volatile anesthesia can decrease force of cardaic ejection * decrease risk of aortic dissection

Answer 32

* Chronic, progressive inflammatory disease involving joints of spine and adjacent soft tissues * associated with HLA B27 in most cases * male to feamle ratio 4:1 * important anesthesia implications both articular and non-articular

Answer 33

* Relieve pain, reduce inflmmation, maintain good posture and function * traditional treatments include NSAIDS, education, exercise, and PT * exercise/PT maintain joint mobility and flexibility * early dx is essential * surgery considered in patients with sever,e advanced dx associated with refractory pain or disability

Answer 34

Difficult intubation associated when AS invovles cervical spine * increased difficulty when TMJ involved * limited mouth opening d/t TMJ involvement * sig risk of neuro injury with any excessive neck extension * progressive kyphosis and spine flexion may limit intubation * risk of occult cervical fracture with minimal trauma * cricoarytenoid arthritis * cords susceptible to trauma

Answer 35

* Aortic regurgitation **(avoid sudden increases in SVR/keep H R\>90 bpm, low normal BP)** * Conduction abrnomalities- BBB * Cardiomegaly

Answer 36

* Pulmonary fibrosis * apical cavity lesions * pleural thickening (similar ot TB) * decreased compliance of chest wall * Decreased VC

Answer 37

* Anesthetic management influence by severity of dx * upper airway involvement * presence of restrictive lung disease * degree of cardiac involvement * may be using neuro monitoring during corrective spinal sx * Awake fiberoptic tracheal intubaiton if spinal deformity is extensive * spinal and epidural anesthesia is technically difficult * may result in an increased risk of complications * consider paramedian approach

Answer 38

* Most common cause of dwarfism * caused by premature ossification of bones combined with normal periosteal bone formation * results in characteristic appearance of short limbs and a relatively normal cranium * often present to OR for sub-occipital creaniectomy for foramen magnum stenosis, laminectomy, VP shunt * consider need for VAE monitoring (sitting crani) * may need right atrial catheter * evoked potential monitoring (limits anesthetic options) * ensures good cerebral circulation

Answer 39

* Normal response to anesthetic agents and NMB * C-section required * cephalopelvic disproportion * kyphoscoliosis and narrow epidural space, spinal canal increase tehcnical difficulty * no evidence based dosing guidlines- epidural may be better so you can titrate local anesthetic slowly * Difficult intravenous and central line access * short neck * excess skin and SQ tissue * Cardiac/pulmonary * pulm HTN leading to cor pulmonale is most common disturbance * restrictive bent defects may occur and lead to pulm htn * central sleep apnea (related to brainstem compression by foramen magnum) and upper airway obstruction

Answer 40

* Facial features lead to dififcult mask management * large protruding forehead, short maxilla with long mandible, flat nose and large tongue * larynx may be small and intubation occasionally difficult * difficult to exposre glottis * range of tube sizes and dififcult airway cart avilable * weight rather than age is best guide for predicting porper size * Foramen magnum stenosis, fusion of atlantooccipital joint with odontoid, atlantoaxial instabilty, buling disc, cervical kyphosis common * **avoid hyperextension during intubation**