Disorder of Nervous and Musculoskeletal Systems Flashcards
Anesthetic Musculoskeletal Assessment: General Principles
with the induction of sedation, regional or general anesthesia we take away the normal protective pain reflexes
- -focus on determining ROM abnormalities & joint integrity (document baseline)
- -maintain natural ROM for all anesthetic procedures and surgical positioning (document)
Assessment of tempromandibular joint
- place tips of index finger just in front of the tragus of the ear - ask patient to open mouth
- fingertips should drop into joint spaces as mouth opens
- check for smooth ROM, swelling/tenderness, pain
- snapping and clicking normal
- ask patient to open and close mouth, protrude & retract (jutting the jaw forward), & perform side to side motion
Cervical spine assessment
flexion = touch chin to chest
extension = look up at the ceiling
rotation = turn the head to each side looking directly over the shoulder
lateral bending = tilt the head touching ear to shoulder
Shoulder Girdle Assessment
- abduct the arms to shoulder level
- raise arms vertical position above head, palms facing each other
- place both hands behind the neck with elbows out to the side
- place both hands behind the small of the back
Thoracic outlet syndrome assessment
thoracic outlet syndrome - compression of brachial plexus and subclavian vessels near the first rib
–be certain patient can work or sleep with arms elevated over their head before putting arms beside head (prone positioning)
Hip assessment
concentrate on ROM that can impact positioning (think lithotomy position especially in a patient with hip hx (osteoarthritis, etc.))
- flexion - supine pt bends each knee to chest/abdomen
- abduction - supine pt, stabilize anterior superior iliac spine and abduct the extended leg until the iliac spine moves = limit!
General nervous system assessment components
- mental status
- speech
- cranial nerves
- gait
- motor function
- sensory function
Cranial Nerve I: assessment
olfactory nerve (smell) --close eyes, have them smell something with a strong smell -- coffee beans, scents for peds in anesthesia cart
Cranial Nerve II assessment
optic nerve
pupillary reaction to light
cranial nerve III assessment
oculomotor nerve
pupillary reaction to light; extraoccular movements
pen test, have patient follow pen with eyes, able to assess cranial nerve III, IV, and VI
cranial nerve IV assessment
trochlear nerve
extraoccular movements
pen test, have patient follow pen with eyes, able to assess cranial nerve III, IV, and VI
cranial nerve VI assessment
abducens nerve
extraoccular movements
pen test, have patient follow pen with eyes, able to assess cranial nerve III, IV, and VI
cranial nerve V assessment
trigeminal nerve
ask the patient to clench his/her teeth as you palpate temporal and masseter muscles
- *check sensation in areas circled (forehead, cheek, chin) (see slide)**
- *corneal reflex (cotton ball)** (when cotton ball touches the eye, should initiate a blink)
cranial nerve VII assessment
facial nerve
Ask patient to:
-raise both eyebrows, frown, close eyes tightly so you can’t open them, show teeth, smile, puff out both cheeks
cranial nerve VIII assessment
vestibulocochlear nerve
acoustic (hearing)
cranial nerve IX and X assessment
glossopharyngeal (IX) and vagus (X) nerves
voice hoarseness, gag reflex (tongue depressor), have them stick their tongue out and say AHHH (palate should rise symmetrically)
cranial nerve XII assessment
hypoglossal nerve
tongue movement, ask them to move tongue side to side
cranial nerve XI assessment
spinal accessory nerve
ask patient to turn head to each side against your hand
ask patient to shrug both shoulders upward against your hand - trapezii strength
Assessment of sensation: C3
front and back of neck (phrenic nerve involvement)
Assessment of sensation: T4
nipple line (think cardiac accelerators)
Assessment of sensation: T10
umbilicus
Assessment of sensation: C8
ring and little fingers (cervical involvement)
Assessment of muscle strength: purpose and scale
Test flexion and extension and compare symmetry
Grade on 0-5 scale
0 - no muscular contraction detected
1 - barely detectable
2 - active movement with gravity eliminated
3 - active movement against gravity
4 - active movement against gravity with some resistance
5 - active movement against gravity with full resistance
Assessment of muscle strength, elbow flexion: which nerve fibers are being tested?
C5 and C6
Assessment of muscle strength, elbow extension: which nerve fibers are being tested?
C6, C7 and C8
Assessment of muscle strength, grip: which nerve fibers are being tested?
C7, C8, T1
Assessment of muscle strength, finger abduction: which nerve fibers are being tested?
C8, T1, ulnar nerve
Assessment of muscle strength, opposition of thumb: which nerve fibers are being tested?
C8, T1, median nerve
Assessment of muscle strength, hip flexion & adduction: which nerve fibers are being tested?
L2, L3, L4
Assessment of muscle strength, hip abduction: which nerve fibers are being tested?
L4, L5, S1
Assessment of muscle strength, hip extension: which nerve fibers are being tested?
S1
Assessment of muscle strength, knee extension: which nerve fibers are being tested?
L2, L3, L4
Assessment of muscle strength, knee flexion: which nerve fibers are being tested?
L4, L5, S1, S2
Assessment of muscle strength, dorsiflexion: which nerve fibers are being tested?
L4, L5
Assessment of muscle strength, plantar flexion: which nerve fibers are being tested?
S1
Head Injury: Glasgow coma scale
Eyes open - never (1) - spontaneous (4)
Best verbal response - none (1) - oriented (5)
best motor response -none (1) - obeys commands (6)
mortality closely related to initial score
scores 8 or less considered severe (coma) - will require intubation and controlled ventilation for ICP & airway control
Who needs steroid supplementation?
any patient who has received corticosteroid therapy (suppression of pituitary adrenal axis) for at least a month in the past 6-12 months needs supplementation
suppression or disease of the pituitary adrenal axis will prevent the pt from responding to the stress of sx appropriately
Describe the 2 possible steroid regimens.
- 100 mg hydrocortisone pre - op, intra - op and post - op
- 25 mg hydrocortisone pre - op + 100 mg IV gtt over 12-24 hours
goal is to mimic natural dosing of cortisol
MAOIs: drugs to look out for
Drugs to look for:
- Iproniazid
- phenelzine
- isocarboxazid
- moclobemide
- befloxatone
- brofaromine
- selegiline
MAOIs: LIFE THREATENING interactions to be aware of.
can occur with
- consumption of foods containing tyramine
- EPHEDRINE
- MEPERIDINE
MAOIs inhibit the degradation of monoamines increasing the serotonin and norepinephrine available at presynaptic nerve terminal for uptake and storage
Conditions where your patient may be taking methotrexate
MS
ankylosing spondylitis
RA
Possible SE and anesthesia considerations to be aware of
- immunosuppression
- anemia
- thrombocytopenia
- pulmonary toxicity
- renal and hepatic toxicity
Anes considerations
-CBC, chem panel, consider PFTs and LFTs if hx warrants
MS: pre op anesthesia questions to consider.
These patients are generally on immunosuppressive medications!
- Any recent hx of illness/infection? – take extra care with infection prevention!
- Which medications are they taking now and how often??
- Steroids in the past year?? - (consider if stress dose is appropriate)
- remission and exacerbation intervals (current exacerbation could warrant postponing an elective procedure)
- severity and nature of symptoms (resp status, previous triggers)
MS, immunomodulators: interferon B SE
flu like symptoms
hepatotoxicity
myelosuppression
depression
MS, immunomodulators: dimethyl fumarate SE
GI discomfort
infections
MS, immunomodulators: glatiramer acetate SE
well tolerated
MS, immunomodulators: natalizumab SE
leukoencephalopathy
hepatotoxicity
MS, immunomodulators: fingolomid SE
bradycardia
hepatotoxicity
MS, immunomodulators: teriflunomide
neutropenia
hepatotoxicity
MS, immunosuppressant drugs: agents + considerations
corticosteroids - exacerbations
mitoxantrone - (severe myelosuppression and cardiac toxicity - reduced EF - HF) — may want to see a recent cardiologist report
MS, symptom management: drugs for bladder dysfunction
alpha antagonists
anticholinergics VS bethanechol)
MS, symptom management: drugs for fatigue and depression
antidepressants
methylphenidate (ritalin)
MS, symptom management: drugs for cognitive dysfunction
cholinesterase inhibitors
memantine
MS, symptom management: drugs for spasticity
baclofen
MS: What pre existing deficits are important to document?
paralysis (assess for motor strength)
sensory disturbances (assess along dermatomes)
autonomic disturbances (resting HR, orthostatic hypotension)
visual impairment (cranial nerve check)
seizures (medications)
emotional disturbances
MS: Counsel patient regarding ________ relapse incidence with surgery.
increased!
MS: Counsel patient regarding ________ relapse incidence with surgery/anesthesia.
increased!
Its not one technique over the other, its just that the stress of the surgery can cause an increased risk of relapse
But also reassure them that all precautions will be taken to minimize risk.
GBS: Important points to document related to time course of disease
- precipitating factors
- onset of symptoms
- disease progression (worsening, stable, improving)
GBS: Documentation of severity and current state of symptoms
- facial paralysis (bulbar involvement) – brain stem involvement! – CONCERNED ABOUT TO ABILITY TO PROTECT AIRWAY AND HEMODYNAMIC STABILITY
- difficulty swallowing - pharyngeal muscle weakness (inc risk of asp)
- impaired ventilation - current vent support required (vent settings)
- dec deep tendon reflexes - lower motor nerve involvement
- extremity paresthesias
- pain - HA, backache, muscle tenderness + note medications helpful for controlling pain
GBS, ANS dysfunction: anesthesia considerations
- review ICU flow sheets for VS trends
- inquire with nurse/pt regarding tolerance of position changes, suctioning, bed baths
- ECG, any recent arrhythmia
- vasoactive medication hx for HTN and hypotension (vasopressors, beta blockers)
Parkinson’s: pre op questions to consider
Current and past symptoms
Oculogyric crisis (when?, how long did it last? what helped?)
ANS symptoms (orthostatic BP)
Hx of pergolide therapy (CV implications)
Temp regulation issues?
Pulm status optimized? (dysphagia and/or dyspnea, pulm infection?)
Parkinson’s: home medication considerations
Continue current medication regimen and note side effects
Levodopa
- -last dose?
- -what happens when you miss a dose?
- -did you bring it with you?
- -make sure pt receives dose in OR if long case
Anticholinergics?
-possibility of HR changes, urinary retention post op
MAOIs?
- avoid meperidine
- use ephedrine WITH EXTREME CAUTION
Parkinson’s: positioning considerations
note the natural ROM for positioning
Parkinson’s: deep brain stimulators and electrocautery
DEACTIVATE before electrocautery (may have to consult with neurosurgeon to make sure that is set up correctly)
Intervertebral Disc Herniation/LBP: anesthesia considerations
Natural ROM for positioning and laryngoscopy (pillow under knees)
baseline motor strength & sensation in applicable areas
medication regimen (pt may be on high dose opioids – what helps? what does not help?)
consider potential for operative blood loss - CBC, type and cross
Ankylosing Spondylitis: potential coexisting conditions and anesthesia considerations
vasculitis
aortitis
aortic insufficiency
pulmonary fibrosis
kyphosis - difficult airways – maybe awake fiberoptic??
—MAY HAVE POSITIONING CHALLENGES - really big consideration in this population, really want to assess natural ROM before they go to sleep
Pre op tests: consider spO2, ECG, Echo, chest xray, PFTs, CBC, BUN, creatinine
DISCONTINUE NSAIDS AT LEAST 2 DAYS PREOP
Acute Spinal cord injury: anesthesia pre op considerations
- level of lesion
- fluid and blood status (CBC, T&C, chem 7)
- ECG/chest xray
- vasopressor requirement (spinal or neurogenic shock?)
- ventilatory support (depending on level of lesion)
- other associated injuries? potential risks
chronic spinal cord injury: pre op anesthesia considerations
- hx of autonomic dysreflexia (what initiated it?)
- old OR/ICU records helpful - response to vasopressors, anesthetics, tracheal suctioning
- ventilatory reserve (level of lesion)
- -C4, C5 accessory muscle involvement
- -C2, C3 phrenic nerve involvement
- -lower than C5 - decent vent reserve
- assessment of skin integrity
- positioning! (note normal of ROM)
What is the optimal time for subsequent elective surgery after stroke?
controversial - thought to be 9 months, but increased time is even better
HISTORY OF RECENT TIA OR CVA INCREASES THE RISK OF PERI OPERATIVE STROKE
Pre/post stroke optimization from emboli
Was the PFO corrected?
Pre/Post stroke optimization from atrial fibrillation
Has the pt been on anticoagulant therapy long enough
Considerations for carotid bruit noted on exam?
- ask pt about TIA symptoms (be aggressive with questioning!!!!)
- asymptomatic bruit - little risk associated
- consider carotid doppler ultrasound study - refer vascular surgeon
CVA, head injury, intracranial tumor: pre op assessment
- mechanism of injury or illness
- location, size, and time course of lesion
- CT or MRI report (secondary edema, hydrocephalus?)
- LOC
- ICP status (HA, n/v, bradycardia, HTN?)
- evaluate CV status (aside from injury/illness, may just have CV comorbidities)
- consider cranial nerve assessment
- consider muscle strength and sensation assessment
- Note baseline VS and set BP parameters (may need to confer with surgeon on goal CO2 range, BP, etc.)
Seizure disorder: pre op questions to consider
- type of seizure activity, typical length, frequency, severity, recovery period
- precipitating/causative factors (underlying disorder, ETOH withdrawal, hypoglycemia, brain tumor)
- Hx of status epilepticus
- –how long did it last?
- –how was it treated?
- –were treatments effective?
Seizure disorder: pre op pharmacologic therapy considerations
- testing directed based on medications - CBC, plt, electrolyte panel common!
- routine levels of anticonvulsants unnecessary in patients with good seizure control (i.e. phenytoin levels)
- cancel elective surgery until seizure disorder optimized by neurologist
SLE: pre op lab considerations
Chem panel - fluid and electrolytes
CBC, PT/PTT, INR - hematologic component of disease
SLE: positioning considerations
note natural ROM - arthritis
note NM strength, cranial and peripheral neuropathies
SLE: skin considerations
note EXISTING rashes - not to be confused with allergic reactions peri op
distal extremities - raynaud’s common - pulse ox reading difficult!
SLE: renal function considerations
glomerulonephritis
proteinuria
ALBUMIN LEVEL, CHEM PANEL
SLE: CV considerations
generally want a full cardiac work up on these pts
- ECHO
- cardiac consult
- pericarditis, conduction abnormalities, CHF, valvular dysfunction?
- EXERCISE TOLERANCE!
SLE: Pulmonary considerations
restrictive lung pattern - PFTs
SLE: GI considerations
prone to N/V - ask what works for them
SLE: drugs that affect coagulation status
ibuprofen indomethacin ASA Cox 2 inhibitors DVT preventative therapy
if in a pre op clinic, may be nice to order them some alternative pain medications so they aren’t too uncomfortable when they come in for sx (since these meds will have to be d/c’d)
SLE: typical medication regimen considerations
- drugs that affect coag status
- immunosuppressive therapy
- steroids (often qualify for stress dose)
RA: focus areas
Airway
neurologic
pulmonary
CV
RA: positioning and airway considerations
- note NATURAL ROM
- TMJ - limited mouth opening?
- atlanto-axial joint - consider lateral neck radiograph or MRI
- cricoarytenoid arthritis - hoarseness, pain on swallowing, dyspnea, stridor, laryngeal tenderness (difficult airway cart in room?, ETT .5 - 1 sz smaller?)
- individualized AW plan based on findings
RA: _________ is often a sign of cardiac ischemia in this population – CV/pulm considerations
DYSPNEA
- question exercise tolerance!
- lung involvement (restrictive pattern) - PFTs, ABG
- cardiac involvement - ECHO, ECG
RA: medication considerations
ASA NSAIDs methotrexate immunosuppressive drugs steroids
balance the preference to continue meds with anti coagulation and immunosuppressive characteristics - review notes from rheumatologist/PCP
Osteoarthritis: anesthesia considerations
Note NATURAL ROM - focus on key problem areas
medications for pain relief, what works what does not work, last dose, etc.
Have to hold NSAIDs around surgery so give them something to bridge their pain control
MG: history taking and anesthesia considerations
note degree of skeletal muscle weakness, progression of disease
–do your best to avoid NMR - if you have to use one, choose a sugammadex reversible agent!
note medication hx
- -cholinesterase inhibitors
- -steroids
- -immunosuppressive therapy
Muscular dystrophy: pre op anesthesia considerations and testing
- note progression of disease
- natural ROM
- muscle strength
- patient will have extrajunctional receptor UP regulation - PUT SUCC AWAY
-delayed gastric motility, high aspiration risk - consider RSI!
- ventilatory status (PFTs, cough strength)
- -discuss goals and potential difficulty of immediate extubation and difficulty getting them off vent at all
- -weigh R/B/A related to elective sx
-cardiac involvement - EKG, perhaps ECHO, exercise tolerance not really appropriate to ask in this population
Myasthenic syndrome: pre op anes considerations
note degree of skeletal muscle weakness and progression of disease
related to lung CA?
medications
Marfans syndrome: pre op anes considerations
cardiopulmonary assessment - ECHO (valve assessment)
TMJ - at risk
High Pneumothorax risk
Ankylosing spondylitis: pre op anes considerations
ROM joints (esp sacroiliac)
pain management hx
ECG (cardiac conduction)
PFT (fibrosis)
medications (methotrexate, NSAIDs, etc.)
