Disease States Flashcards
1
Q
Achondroplasia
A
- airway: craniofacial and spinal abnormalities, limited neck extension, large tongue, large mandible, A-A instability
- kyphosis/scoliosis/spinal stenosis: difficult and unpredictable epidurals and spinals
- comorbidities: OSA, obesity
2
Q
Acromegaly
A
- GH hypersecretion: usually from GH secreting pituitary adenoma, may have panhypopituitarism (need hydrocortisone and thyroxine)
- potentially difficult airway/mask: gigantism and facial bone hypertrophy, large tongue, mucosal hypertrophy, prominent jaw, OSA
- comorbidities: OSA, HTN, cardiac arrhythmias, diastolic dysfunction, CAD, glucose intolerance, renal failure
3
Q
Acute Porphyrias
A
- group of inherited enzymatic defects of heme synthesis
- overproduction of heme precursors and intermittent symptomatic attacks
- multisystem manifestations: neuro, renal and CV
- S&S: abdominal pain, N/V, autonomic and peripheral neuropathies, electrolyte disturbances, hypovolemia, bulbar dysfunction, respiratory failure, mental status changes, seizures, coma
- drug triggers: barbiturates, Etomidate, ketorolac, metoclopramide, steroids
- nondrug triggers: dehydration, fasting, stress, infection
- Preop
- severity and susceptibility of disease, precipitating factors, treatments, and current symptomatology
- ensure adequate hydration, glucose, and anxiolytics
4
Q
Adrenal Insufficiency
A
- primary (cortisol/aldosterone) versus secondary (ACTH)
- labs: hyponatremia, hyperkalemia, hypoglycemia
- Addisonian crisis S&S (life threatening!): hypotension, dehydration, circulatory collapse, vomiting/diarrhea, hypoglycemia, acidosis, hyponatremia, hyperkalemia, abdominal pain, loss of consciousness
- Addisonian crisis rx: hydrocortisone 100 mg q6h
5
Q
Adrenocortical Excess (Cushing Syndrome)
A
- source of corticosteroid: pituitary (Cushing disease), adrenal, paraneoplastic, or exogenous
- S&S: HTN, increased ICP, LVH, OSA
- labs: hypokalemia, hypocalcemia, increased hgb, hyperglycemia
6
Q
Alcoholism
A
- multisystem disease: neuro (peripheral neuropathy, Wernicke-Korsakoff), CV (tachycardia, HTN, cardiomyopathy), respiratory (pneumonia, smoking), GI (reflux, gastritis), liver (fatty, hepatitis, cirrhosis), pancreatitis, heme (pancytopenia)
- withdrawal: BZs (diazepam) and thiamine
7
Q
Amyotrophic Lateral Sclerosis (ALS)
A
- aspiration risk (bulbar palsy)
- altered responses to NMBDs: hyperkalemia w/sux, prolonged response to NDMR
- increased risk for postop PPV
- potential autonomic dysfunction
8
Q
Anterior Mediastinal Mass
A
- 4 T’s: thymus, thyroid, terrible lymphoma, teratoma and germ cell tumors
- lymphoma most common
- other options for dx: CT guided needle biopsy, awake anterior mediastinoscopy w/LA
- consider empiric chemo/rad/steroids to decrease size of mass
- may require ECMO or CPB (severe positional symptoms)
- H&P: chest pain, dyspnea, orthopnea and position changes, syncope
- SVC syndrome: stridor, cyanosis, venous engorgement of neck, edema of head and neck
- labs/imaging: CBC, ECG, CT, echo, +/- flow-vol loops (intra-thoracic obstruction)
- MAINTAIN SPONTANEOUS VENTILATION
- Airway and/or vascular compression
1. if possible, awake patient
2. reposition (determine preoperatively what relieves compression)
3. rigid branch and ventilation distal to obstruction
4. sternotomy and surgical elevation of mass off compressed airway and/or vessels - Avoid muscle relaxants until manual ventilation ensures ability to give PPV
- > 50% tracheobronchial compression precludes safe GETA
- Flow volume loops: risk of airway collapse during induction supposed to correlate with increase in mid-expiatory phase plateau when going from upright to supine, but NOT borne out with studies
- Fixed obstruction (intra or extra thoracic): limited during inspiration and expiration (hamburger)
***Flow volume loops not mandatory: CT combined with H&P observing patient in sitting, supine, and possibly prone positions gives all the required information
9
Q
Aortic Dissection
A
- intimal tear in aorta
- Stanford types: A begins in ascending, B begins in descending
- DeBakey types: 1 involves whole aorta, 2 is just ascending, 3 is just descending
- Type A requires surgery (+/- AV and coronaries), risk of stroke
- Type B may be treated medically, endovascular; risk of spinal cord ischemia
- Risks: atherosclerosis, HTN, Ehlers-Danlos, Marfan
- strict control of BP (SBP <120 mmHg)
10
Q
Burns
A
- Body surface area “rule of 9’s”: head 9%, arms 9% each, legs 18% each, chest 18%, back 18% (head is 18% for children)
- Parkland formula: 4 cc/kg/%BSA over 24 hours (half in first 8 hrs, half in next 16 hours)
- avoid sux after 24 hours
- consider CO poisoning and hyperbaric O2 therapy
- concerns: airway, IV access, fluid resuscitation and UO, hypothermia, infection, compartment syndrome, blood product needs
CV changes
- First 48 hours: CO decreased due to circulating myocardial depressants, increased SVR, contracted plasma volume (increased capillary permeability and third spacing), decreased response to catecholamines
- After 48 hours: capillary integrity returns (if adequate fluid resuscitation), interstitial fluid reabsorption, increased metabolic demands, and increased circulating catecholamines lead to a hyper dynamic state (increased CO and decreased SVR from circulating inflammatory mediators)
*airway edema (3rd spacing, inhalation injury), hypovolemia/shock (increased vascular permeability, edema, 3rd spacing, extravasation of proteins, fluid shifts to interstitial compartments), hyperkalemia (tissue destruction), myocardial depression (circulating depressants from tissue injury), diminished response to catecholamines
11
Q
Carcinoid
A
- tumors of GI tract (also bronchi/lungs)
- contain a variety of hormones: serotonin, histamine, substance P, PGs, kallikrein, etc
- carcinoid syndrome: systemic release of serotonin, histamine, etc. (usually from liver mets or non-GI tumors)
- ->flushing, edema, diarrhea, bronchoconstriction–>can progress to TR/PR and PS leading to RV failure
- carcinoid crisis: d/t handing of tumor during surgery–>bronchoconstriction, hypotension (sometimes HTN), hyperglycemia
- tx: octreotide (somatostatin analogue), antihistamines
- caution: ketamine, morphine, catecholamines (epi), mivacurium, atracurium
- caution: sux (risk of mediator release–>contractions/histamine)
12
Q
Cardiac Tamponade
A
- obstructive shock: increased intrapericardial pressures leads to cardiac compression and obstructive shock (decreased CO/BP)
- compensation: tachycardia, increased SVR, increased contractility (sympathetic activation)
- pulsus paradoxus: inspiratory fall in SBP >10 mmHg
- Kussmaul sign: JVP distends with inspiration
- ECG: may have electrical alternans (alteration of QRS axis or amplitude between beats)
- Echo: compressed chambers, diastolic collapse of RA/RV
- Avoid PPV: decreased venous return–>decreased CO
- Induction with ketamine or etomidate
- Spontaneous ventilation until tamponade relieved
13
Q
Cerebral Aneurysm
A
- SAH complications: rebreeding, mass effect, brain edema, seizures, vasospasm, cardiac arrhythmias, neurogenic pulmonary edema
- Triple H treatment for vasospasm: HTN, hypervolemia, and hemodilution (also early angioplasty, nimodipine/nicardipine)
- Brain protection: maintain CPP >60 mmHg; normocapnia; avoid hyperglycemia/acidosis/hypoxia; mild hypothermia (32-34 degrees); seizure prophylaxis
14
Q
Chronic Renal Failure
A
- comorbidities common: CAD, HTN, DM
- considerations: volume overload, electrolytes abnormalities (hyperK, hyperMag, hypoCa), uremia, pharmacokinetic changes due to decreased elimination and decreased albumin
- uremia: encephalopathy, autonomic/peripheral neuropathy, pleural/pericardial effusions, anemia, platelet dysfunction
- Cr>2.0 independent risk factor for cardiac complications
- avoid really excreted drugs: morphine, meperidine, pancuronium
15
Q
Cystic Fibrosis
A
- genetic mutation for protein (CF transmembrane regulator) found on most exocrine glands
- changes in pulmonary, GI, GU, sweat glands
- resp: obstructive disease, viscous mucous secretions w/reduced mucociliary clearance leading to airway inflammation and chronic infection and chronic hypoxia/hypercarbia (PAH/cor pulmonale)
- pancreas: protein/fat malabsorption (vit K), DM
- hepatobiliary: fatty liver, cirrhosis, portal HTN
- labs: CBC, lytes, LFTS, coags, glucose
- other: CXR, echo?, PFTs
16
Q
Down Syndrome
A
- airway/pulmonary: AAI, mid-face hypoplasia, macroglossia, subglottic stenosis, OSA, PAH
- CV: ASD, VSD, endocardial cushion defects, tetralogy of Fallot
- GI: higher incidence of GERD, TEF
- Endocrine: hypothyroidism
17
Q
Duchenne Muscular Dystrophy
A
- most common childhood muscular dystrophy
- affects skeletal, cardiac, and smooth muscle
- death due to respiratory failure
- cardiac (cardiomegaly, cardiomyopathy), resp (PNA, aspiration, failure), and GI (gastroparesis, smooth m.)
- kyphoscoliosis can lead to pulmonary hypoplasia, RLD, and V/Q mismatching–>hypoxia, hypoxic pulmonary vasoconstriction, and hypercapnia lead to pulmonary HTN and RV failure
- anesthetic risk: rhabdomyolysis and hyperkalemia (triggered by inhalation agents and succinylcholine)
- NOT at elevated risk of MH (but makes ddx challenging)
- MH (hyper metabolism): increased CO2, metabolic acidosis, muscle rigidity, elevated temp >38.8
- trigger free anesthetic (no volatiles or sux)–>no inhalation induction
- NDMRs: more sensitive and longer duration
- rhabdo/hyperK tx: calcium chloride, bicarb, insulin/dextrose, hyperventilation, IV hydration, mannitol to promote diuresis
18
Q
Eisenmenger Syndrome
A
Goals
- maintain SVR and avoid decreases in SVR (increased R–>shunt)
- avoid increases in PVR: avoid dehydration, pain, acidosis, hypoxia, hypercarbia, hypothermia, high PEEP, increased intrathoracic pressure
- CHF mgmt: digoxin, diuretics
- avoid air bubbles: paradoxical air embolus
- pulmonary vasodilator: prostacyclin, epoprostenol, bosentan, or sildenafil; inhaled NO may be useful intro
- IV induction preferred over inhalation if CHF
19
Q
Epiglottitis and Croup
A
- epiglottitis: minimal cough, sudden stridor, “toxic” appearance, dysphagia, drooling
- epiglottitis: associated w/H. influenza
- croup: barky, unproductive cough, hoarseness, gradual stridor, mild fever, minimal dysphagia, no drooling; often improves w/nebulized epinephrine and steroids
- croup: associated with parainfluenza viruses
- ddx: FB aspiration, tracheitis, tonsillitis, retropharyngeal abscesses, vascular rings, allergic reaction, laryngeal diphtheria
- imaging: epiglottitis w/”thumb sign”, croup w/”steeple sign”
- tx: steroids, nebulized epi, heliox, broad spectrum antibiotics for epiglottitis
- airway: ETT w/inhalation induction, surgical backup for trach
