Exam 2 Flashcards
1
Q
Nasal intubation passes tube through which meatus
A
inferior turbinate/ meatus
2
Q
What is the pharynx responsible for, location
A
Airway patency
obstruction
musclar tube from the back of skull to the border of the cricoid cart
join nasal and oral cavities down to the esophagus
3
Q
Primary cause of airway obstruction in anesthesia
A
loss of phayngeal muscle tone
4
Q
Nasopharynx
A
nose to soft pallet
5
Q
oropharynx
A
soft pallet to epiglottis
6
Q
Hypopharynx
A
Epiglottis to cricoid cart
7
Q
Larynx
A
Epiglottis to lower end of cricoid cartilage (6th cervical vertebrae)
Responsible for; Inlet to trachea
Phonation
Airway protection
8
Q
Unpaired Laryngeal cartilages
A
Thyroid- largest (support soft tissue)
Cricoid
Epiglottis
9
Q
Paired Laryngeal cartilages
A
Arytenoid
Corniculate
Cuneiform
10
Q
Where does the vocal ligament attach
A
artenoid cartilage and the thyroid cart at the thyroid notch
11
Q
Trachea extends, length, shape, closed by, bound to?
A
Extends from inferior cricoid membrane to carina
10 to 15 cm - adult
C-shaped cartilage
Closed posteriorly by longitudinal trachealis muscle
Anteriorly bounded by tracheal rings
12
Q
Reasons for receiving difficult airway notice
A
difficult mask ventilation
difficult laryngoscopy
difficult intubation or failed intubation
13
Q
Inter-incisor distance
A
Mouth opening
Prefer > 6 cm (3 finger breadths)
14
Q
Large tongue name
A
Macroglossia
15
Q
Edentulousness meaning
A
lack of teeth – lack of teeth = hard to ventilate
16
Q
Sniffing position
A
Cervical flexion and atlanto-occipital extension
Aligns oral, pharyngeal, and laryngeal axis
17
Q
sternomental distance
A
Distance between sternal notch and chin
Head in full extension
Mouth closed
>12.5 cm preferred
18
Q
Thyromental distance
A
Submandibular compliance
Prefer > 6.5 cm (3 finger breadths)
Tip of chin to thyroid notch
19
Q
Prognathic ability
A
Extension of lower incisors beyond upper incisors
Upper lip bite test
20
Q
Mallampati Test
A
The patient is seated upright with head neutral
Mouth open
Tongue protruded
No phonation
Visibility of oropharyngeal structures
Class I - IV
21
Q
Mallampati class I
A
Fauces (arch), pillars (tonsils), entire uvula, and soft palate
22
Q
Mallampati class ii
A
Fauces, portion of the uvula, and soft palate
23
Q
Mallampati class iii
A
Base of the uvula and soft palate
24
Q
Mallampati class iv
A
Only hard palate
25
BURP
External manipulation and backward, upward, rightward pressure
26
Optimal external laryngeal manipulation (OELM)
Move the larynx to align up glottis
27
Cormack-lehane classification
Classification of laryngeal view/ view of the glottis
Grade I-IV
28
CL- Grade 1
Entire full glottis
29
CL- Grade 2
Only the posterior portion of the glottis
30
CL- Grade 3
No part of the glottis and only epiglottis
31
CL- Grade 4
Epiglottis cannot be seen
32
Criteria associated with difficult mask ventilation (OBESE)
Obesity, BMI > 30kg/m2
Beard
Edentulous
Snorer, OSA
Elderly, male Age > 55
Mallampati 3 or 4
33
Reasons to do an awake intubation
Suspected difficult laryngoscopy
Suspected difficult ventilation with face mask/supraglottic airway
Significant increased risk of aspiration
Increased risk of rapid desaturation
Suspected difficult emergency invasive airway
34
Achalasia
Esophageal outflow obstruction d/t inadequate relaxation of the LES
Dilated hypomotile esophagusLES hypertension and reduced peristalsis
35
LES normal resting tone
29 mmHg
> 29 hypertensive
36
s/s of Achalasia and risk
dysphagia (solids/liquids),
regurgitation,
heartburn,
chest pain
RISK;
Aspiration (sleep sitting up)
Esophageal CA
37
TX for achalasia
relieves obstruction… not peristalsis.
Nitrates, CCB, - low dose
Botox, - relax LES
pneumatic dilation, - balloon inflates in the distal esophagus to dilate and inflate.
Heller myotomy, - cutting smm at LES (distal to esoph and fundus of stomach)
per oral endoscopic myotomy (POEM)
38
Anesthesia Concerns for Achalasia and npo
aspiration ➔ RSI or awake intubation
POEM – NPO up to 48 hours (decreased peristalsis)
Heller still should be NPO for 24-48 hr
39
Distal Esophageal Spasm, dx and tx
Spastic distal esophagus
Mimics anginal pain
DX; Esophagram-Cork screw or rosary bead appearance
TX: Nitroglycerin, trazodone, and imipramine (antidepressants), and sildenafil (PDI)
40
Esophageal diverticula tx
Esophageal wall outpouching
tx; removal
41
Esophageal diverticula Locations/ names
Pharyngoesophageal (Zenker’s diverticulum)
Mid-esophageal
Epiphrenic (supradiaphragmatic diverticulum)
42
Esophageal diverticula s/s
Bad breath
Dysphagia
43
Esophageal diverticula anesthesia
Aspiration risk
No cricoid pressure
Intubate w/ head elevated
Avoid NGT or OGT- risk perforating
44
Odynophagia
pain w/ swallowing. Hx of esophagitis. Or esophageal ulcers
45
Globus sensation
lump in throat. “psych problem”.
46
Hiatal hernia
Part of the stomach enters the thoracic cavity through esophageal hiatus (diaphragm)
Not generally repaired
47
Sliding hiatal hernia
GE junction and fundus slide upward
48
Paraesophageal hernia
GE junction doesn’t move
Pouch of stomach herniates next to the GE junction through esophageal hiatus
49
Esophageal Tumors location and type
Progressive dysphagia and weight loss
Squamous cell- mid esophagus
adenocarcinomas- distal (most common)
50
Esophageal Tumors s/s
Pancytopenia
Dehydration
Lung injury (post-chemo and radiation)
Malnourishment
51
Esophageal Tumors tx
Esophagectomy, chemotherapy, or radiation
52
GERD
Reflux causing esophageal mucosal injury or at extraesophageal sites (and upward)
<29 mmhg usually 13 mmhg
53
Anti-reflux mechanisms
LES,
crural diaphragm- sit where LES is
GE junction location- lower than crural
LES pressure- (gerd = hypotesive)
54
GE junction/LES incompetence
Transient LES relaxation
LES hypotension
Anatomic distortion of GE junction (hernia)
55
GERD s/s
Heartburn
Regurgitation
Dysphagia
Chest pain
chronic cough
56
GERD complications
Esophagitis
Laryngopharyngeal reflux variant (chronic cough)
Recurrent pulmonary aspiration
57
GERD tx
Lifestyle modification- avoid high fat/ acidic food, avoid drinking, peppermint.
PPIs > H2 antagonists
Nissen fundoplication- wrap fundus and illeus to make stronger.
58
GERD Anesthesia concerns and meds to give pre op
Aspiration risk
Cimetidine and ranitidine (works better)
Famotidine (longer duration of action)> cimetidine
PPIs- day or or day before sx.
Sodium citrate + metoclopramide - DM, MO, and pregnant pts
RSI + cricoid pressure
59
PH of stomach acid
2.5
60
Peptic Ulcer Disease where and s/s
Ulcers in the mucosal lining of stomach or duodenum
Burning epigastric pain- usually w/ worsening ulcers/ with fasting
61
Primary cause of peptic ulcer disease
Helicobacter pylori - protinflammatory cytokines = effect parietal cells = reduce duodenal muscousa bicarb
62
Gastric ulcer and causes
usually in body of the stomach
Form of PUD
NSAIDs – common cause
H. pylori + NSAIDs use
63
Peptic Ulcer Disease risk factors for death
Bleeding
Peritonitis- from perforation
Dehydration
Perforation
Sepsis
64
Peptic Ulcer disease population it effects
etoh
elderly
65
Peptic Ulcer disease Complications
Bleeding -Mortality 10% to 20%
Perforation- Untreated duodenal ulceration - 10% risk, Sudden and severe epigastric pain
Gastric outlet obstruction
66
Gastric outlet obstruction s/s and anesthesia concerns
Acute or slow development
S/S: vomiting, dehydration, and hypochloremic alkalosis
Anesthesia Consideration
Full stomach (RSI), NGT, hydration, IV antisecretory drugs (ex: PPIs)
67
PEPTIC ULCER DISEASE Treatment
Antacids,
H2 Receptor Antagonists
PPIs
Prostaglandin Analogues
Cytoprotective agents
68
H2 Receptor Antagonists
Inhibits basal and stimulated HCL secretion
Cimetidine, ranitidine, famotidine, and nizatidine --more potenta and longer duration of action- tx for 4-6 weeks
69
PPIs
Inhibits all phases of gastric acid secretion
Omeprazole, pantoprazole
70
Prostaglandin Analogues
Maintains mucosal integrity
Misoprostol
71
Cytoprotective agents
Creates physicochemical barrier
Sucralfate
peptobismol
72
Antacids
OTC for symptomatic relief of dyspepsia
Aluminum/magnesium hydroxide
Calcium carbonate
73
Peptic Ulcer Disease Treatment for H pylori
Triple combination therapy – 14 days
PPI (2 x strength) + 2 ABXs - Clarithromycin and amoxicillin or metronidazole, tetracycline
74
Peptic Ulcer Disease surgical Treatment
Correcting immediate problem
Hemorrhage, perforation, and obstruction
remove source and fix anatomy, prevent long term complications/ SE.
75
Peptic Ulcer Disease surgical Treatment
Correcting immediate problem
Hemorrhage, perforation, and obstruction
remove source and fix anatomy, prevent long term complications/ SE.
76
Peptic Ulcer Disease surgical Treatment
Correcting immediate problem
Hemorrhage, perforation, and obstruction
remove source and fix anatomy, prevent long term complications/ SE.
77
Dumping Syndrome
Emptying hyperosmolar gastric contents into proximal small bowel
Release of vasoactive GI hormones (histamin, ang 2, NO, bradykinin)
78
Dumping Syndrome
Emptying hyperosmolar gastric contents into proximal small bowel
Release of vasoactive GI hormones (histamin, ang 2, NO, bradykinin)
79
Dumping Syndrome tx
Dietary modifications- more glucose or carbs with meal
Octreotide therapy
80
Dumping sydrome late and early s/s
Early – 15-30 mins post-prandial
Nausea, epigastric discomfort, diaphoresis, crampy abd pain, diarrhea, tachycardia, palpitations, dizziness or syncope
Late – 1-3 hours post-prandial
Vasomotor symptoms secondary to hypoglycemia d/t excessive insulin release
81
Ulcerative colitis s/s
Diarrhea, rectal bleeding, tenesmus, passage of mucous, crampy abdominal pain, anorexia, N/V, fever, and weight loss
82
tenesmus
constant urge to go to the bathroom
83
Inflammatory bowel disease Ulcerative colitis
Mucosal disease…. All or most of the colon to rectum
severe- hemm
84
Ulcerative colitis Complications
Massive hemorrhage
Toxic megacolon- dilated transverse colon, loss of segments.
Obstruction
Perforation
85
Ulcerative colitis tx
Total proctocolectomy- curative
removing colon and rectum.
86
crohn's diesease
Acute or chronic bowel inflammation at terminal ileum/cecal valve- connection of small bowel and large bowel
87
Crohns disease s/s
Weight loss,
inflammatory mass,
bowel spasm,
postprandial pain
Malnutrition,
steatorrhea,
stricture formation- narrowing -> obstruction
88
crohn's disease complications
Stricture, obstruction, abscess, or fistula
89
crohn's disease tx/ sx
Small bowel resection d/t fistula or obstruction
Total protocolectomy w/ end ileostomy- not curative
90
Inflammatory bowel disease Medical treatment
5-Acetylsalicylic acid (5-ASA)- Anti-inflammatory
Glucocorticoids- UC and Crohn's
ABX – Ciprofloxacin or metronidazole
Azathioprine and 6-mercaptopurine- Purine analogues
Methotrexate and cyclosporine
Immunosuppressive
91
Carcinoid tumors og,secretes
Originate from the GI tract
<25% in lung tissue
Secrete GI peptides and/or vasoactive substances
Insulin, histamine, serotonin
92
foregut
Thymus,
esophagus
lung
stomach
duodenum
pancreas
93
Midgut
appendix
ileum
ascending colon
94
Midgut
appendix
ileum
ascending colon
95
hindgut
distal large bowel
rectum
96
Seretonin secreted location
high in midgut
low in forgut and rare in hindgut
97
Carcinoid sydrome location
atypical in foregut
typical in midgut
rare in hindgut
98
CARCINOID TUMORS WITHOUT CARCINOID Syndrome
found with appendecomy- may or may not remove.
99
CARCINOID TUMORS W/ SYSTEMIC SYMPTOMS D/T SECRETED PRODUCTS
GI peptides and /or vasoactive substances- found in midgut over the foregut
Midgut carcinoids (produce more mediators) > foregut carcinoids
Non-producing tumors- present as mass or bowel obstruction.
100
Small intestine carcinoid presentation w/ %
abd pain (51%), intestinal obstruction (31%), tumor (17%), GI bleed (11%)
101
Rectrum carcinoid presentation
Bleeding (39%), constipation (17%), Diarrhea (17%)
102
Bronchus Carcinoid presentation
Asymtomatic (31%)
103
Carcinoid tumors carcinoid syndrome s/s
Serotonin and vasoactive substances released in systemic circulation
Serotonin - diarrhea
Histamine - responsible for puriting flushing
Both for bronchoconstriction
Signs and symptoms
Flushing, diarrhea, hypotension, HTN, bronchoconstriction, wheezing
104
Carcinoid tumors Carcinoid crisis
Intense flushing, diarrhea, abdominal pain, tachycardia, HTN or hypotension
Fatal w/o treatment
Spontaneous or provoked by stress, chemotherapy, or biopsy
105
Drugs that may provoke mediator release
sux, mivacurium, atracurium, tubocurarine, epi, ne , dop , isoprterenol, thiopental
106
Carcinoid tumors treatment
Serotonin blockers
Histamine blockers
Somatostatin analogues (>80% patients)
Octreotide, histamine blockers, and ipratropium
107
Serotonin blockers
5HT1/2 - diarrhea
5HT3 (ondansetron) – diarrhea and nausea; occasionally relieve flushing
108
Histamine blockers
prevent Flushing
109
Somatostatin analogues
(>80% patients)
Prevents crisis development
Lanreotide (most common, SUBq x 4wks)
Octreotide (24-28 before sx)
110
Octreotide, histamine blockers, and ipratropium prevent…..
prevent Bronchoconstriction
111
Autodigestion prevented by protective mechanisms for pancrease
Packaging of proteases in precursor form
Synthesis of protease inhibitors
Low intra-pancreatic concentration of calcium
112
Causes of pancreatitis
Gallstones and ETOH abuse - 60% to 80%
AIDS, hyperparathyroidism, and trauma
113
Acute Pancreatitis signs and symptoms
Mid-epigastric pain, N/V, abd distention (ileus)
Dyspnea, low-grade fever, tachycardia, hypotension
Shock d/t hypovolemia
Increased serum amylase and lipase
114
Acute pancreatitis ranson criteria
> 55 years
WBC count > 16,000 cells/mm3
BUN >16 mmol/L
Aspartate transaminase > 250 units/L
Arterial PaO2 < 60 mmHg
Fluid deficit > 6 L
Blood glucose > 200 mg/dL w/o a history of DM
Lactate dehydrogenase > 350 IU/L
Corrected calcium concentration < 8 mg/dL
Fall in Hct >10%
Metabolic acidosis with a base deficit > 4 mmol/L
Mortality r/t number of criteria present
0-2 criteria <5% mortality
3-4 criteria 20% mortality
5-6 criteria 40% mortality
7-8 criteria 100% mortality
115
Acute pancreatitis complications
DIC
ARDS
SHOCK
Renal Failure
Hypotension
Arterial hypoxemia
infection of the necrotic panc material or abscess formation
25% of pts experience complications
116
Acute pancreatitis Treatment
Aggressive IVF administration
Colloid replacement
NPO
Enteral/TPN
NGT suction
Pain management
Removal of gallstones
117
Chronic pancreatitis how and causes
Persistent inflammation w/ irreversible damage
Loss of exocrine and endocrine function
Chronic ETOH abuse, CF, and hyperparathyroidism
118
Signs and symptoms of Chronic pancreatitis
Post-prandial, epigastric pain
Thin, emaciated, steatorrhea
DM
119
Treatment of Chronic pancreatitis
Management of pain, DM, and malabsorption
120
Gi bleeding Upper acute s/s
Hypotension and tachycardia w/ blood loss >25% of total blood volume
Hct - normal
Anemia
Orthostatic hypotension – Hct <30%
BUN >40 mg/dL
121
Causes of Gi bleeding Upper acute
Esophageal variceal bleeding, malignancy
122
Gi bleeding Upper tx
Upper endoscopy
Active bleeding
------Endoscopic coagulation (burn, clips)
123
Gi bleeding Upper Anesthetic Considerations
Aspiration risk – ETT… RSI
124
GI bleeding Lower and causes
Abrupt passage of bright red blood and clots via the rectum
Diverticulosis, tumors, ischemic colitis, infectious colitis
125
GI bleeding Lower tx
Sigmoidoscopy/colonoscopy
Angiography and embolic therapy
Surgery
126
Part of properly assessing Mallampati includes:
* NO phonation
127
2. What is the LEAST LIKELY cause of dental injury during anesthesia?
* Aggressive mask ventilation
128
3. Prognathic ability is a measurement of:
* The extension of the lower incisors beyond the upper incisors.
* The ability of the lower incisors to bite the upper lip.
129
4. What information regarding the patient’s anesthetic history would indicate a potential airway concern?
* Report of cut lips and broken teeth.
* Report of excessive sore throat.
130
5. Which airway assessment finding is more predictive of difficult intubation than a high BMI>
* Cervical traction.
131
1. A 34-year-old patient diagnosed with acute pancreatitis is scheduled for surgery in the morning. The patient has the following laboratory values:
WBC: 18,000
Platelets: 150,000
AST: 376
BUN: 22
What is the patient’s risk for mortality?
* 40%
132
2. An adenocarcinoma esophageal tumor is located at:
* At the mid-esophagus
133
3. Which medication will induce remission in patient with Ulcerative Colitis and Crohn’s disease?
* 5-Acetylsalicylic acid
134
4. For patients with a history of esophageal diverticula, what are the anesthetic concerns?
* Increased risk of aspiration
* Apply cortical pressure during induction.
135
. In a patent with carcinoid tumors, how early should octreotide be administered to prevent crisis during surgery:
* 24 hours!
136
1.Which statement BEST describes acromegaly?
* Decreased amount of neuromuscular blockers is recommended.
137
2.Which anesthetic plan is ideal for a patient with systemic lupus erythematosus?
* Order pre-operative CBC and ECG.
138
3.Preoperative findings of Duchenne muscular dystrophy include:
* Kyphoscoliosis
139
4.Signs and symptoms of scleroderma include:
Small bowel hypomotility.
* Decreased pulmonary compliance.
140
5.Anesthetic considerations for syndrome of inappropriate anti-diuretic hormone (SIADH) include:
* Measurement of urine osmolality.
* Titrating intravenous fluid.
141
6.A diagnosis of Grave’s disease is consistent with:
* Weight loss.
142
7.In patients with carcinoid tumors, how early should octreotide be administered to prevent crisis during surgery:
* 24 hours.
143
8.All of the anesthetic considerations are indicated in a patient with hyperparathyroidism EXCEPT:
* Administration of 40 mg of rocuronium.
o Pre-operative ECG.
o Avoiding the use of midazolam pre-operatively.
o IV fluid administration.
144
9.Which statement BEST characterizes myasthenia gravis?
* Fatiguability of skeletal muscle with repetitive use.
145
10.What are treatments indicated for a patient with rheumatoid arthritis?
* Corticosteroids and DMARDS.
146
Scleroderma
Inflammation and autoimmunity
Vascular injury with vascular obliteration
Tissue fibrosis and organ sclerosis
147
Xerostomia
dry mouth
148
CREST syndrome
s/s of scleroderma
calcinosis
Raynauds
Esophageal dysfunction
sclerodactyly- thick and tight skin
Telangiectasis- cap dilation
Skin: Taut skin
MS: Limited mobility/contractures, skeletal muscle myopathy
Nervous System: Nerve compression
CV: Systemic and pulmonary HTN, dysrhythmias, vasospasm in small arteries of fingers, CHF
Pulmonary: Diffuse interstitial pulmonary fibrosis, decreased pulmonary compliance
Renal: Decreased renal blood flow and systemic HTN
GI: Xerostomia, poor dentition, fibrosis of GI tract, reflux
149
Scleroderma Treatment
Alleviating symptoms…
ACE-I
150
Scleroderma Anesthesia Management
Airway: Mandibular motion, small mouth opening, neck ROM, oral bleeding
hard stick
Decreased pulmonary compliance and reserve, avoid increasing PVR
GI: Aspiration
Eyes: corneal abrasions
Regional anesthesia
Keep warm
VTE prophylaxis
Positioning
Pulse ox difficulties
151
Pseudohypertrophy Muscular Dystrophy Duchenne Muscular Dystrophy (DMD)
what and who
Mutation in the dystrophin gene
Fatty infiltration = pseudohypertrophic
2-5 y/o boys
152
Duchenne Muscular Dystrophy (DMD) initial s/s
waddling gait, frequent falling, difficulty climbing stairs
153
Pseudohypertrophy Muscular Dystrophy S/S
CNS: Intellectual disability
MS: Kyphoscoliosis, skeletal muscle atrophy, serum CK 20-100x normal
CV: Sinus tachycardia, cardiomyopathy, EKG abnormalities
Pulmonary: weakened respiratory muscles and cough, OSA
GI: Hypomotility, gastroparesis
154
Pseudohypertrophy Muscular Dystrophy Anesthesia Management
Airway: weak laryngeal reflexes and cough
Pulmonary: weakened muscles
CV: Pre-op EKG and/or echo based on the severity
GI: Delayed gastric emptying
Avoid succinylcholine
Pharyngeal and respiratory muscle weakness
Rhabdomyolysis
MH – increased incidence; Dantrolene
Regional > GA
155
Myasthenia Gravis
Chronic autoimmune disorder
NMJ - Decreased functional post-synaptic ACh receptors
Muscle weakness w/ rapid exhaustion of voluntary muscles
Partial recovery with rest
ACh receptor-binding antibodies and thymus abnormalities
156
Myasthenia Gravis S/S
Ptosis, diplopia, and dysphagia
Dysarthria and difficulty handling saliva
Isolated respiratory failure
Arm, leg, or trunk muscle weakness
Myocarditis
Autoimmune diseases associated
-RA, SLE, pernicious anemia, hyperthyroidism
157
Myasthenic crisis w/ s&s
Drug resistance or insufficient drug therapy
S/S: severe muscle weakness and respiratory failure
158
Cholinergic crisis w/ s&s
Excessive anticholinesterase treatment
S/S: muscarinic side effects – profound muscle weakness, salivation, miosis, bradycardia, diarrhea, abdominal pain
159
Edrophonium/Tensilon Test
1-2 mg IVP
Improves myasthenic crisis, makes cholinergic crisis worse
160
Myasthenia Gravis Treatment
Anticholinesterases
-First line of treatment
-Pyridostigmine > neostigmine
Thymectomy
-Induces remission
-Reduced use of immunosuppressives
-Reduces ACh receptor antibody levels
-Full benefit delayed
Immunosuppression
-Corticosteroids, azathioprine, cyclosporine, mycophenolate
Immunotherapy
-Plasmapheresis
--Removes antibodies from circulation
-Immunoglobulin
--Temporary effect
161
Myasthenia Gravis Anesthesia Management
Aspiration risk
Weakened pulmonary effort
Marked sensitivity to nondepolarizing muscle relaxants
Resistance to succinylcholine
Intermediate-acting muscle relaxant
Intubate without NMBD
162
Osteoarthritis complications and OG
Degenerative process affecting articular cartilage
Minimal inflammation
Joint trauma
Pain present with motion, relieved by rest
Weight-bearing and distal interphalangeal joints
Heberden nodes
Degenerative disease – vertebral bodies and intervertebral disks
Protrusion of the nucleus pulposus
Compression of nerve roots
Middle to lower c-spine and l-spine
163
Osteoarthritis Treatment
PT and exercise
Maintaining muscle function
Pain relief
Joint replacement surgery
164
Osteoarthritis Anesthesia Management
Airway
Limited ROM
165
Rheumatoid Arthritis
Autoimmune-mediated, systemic inflammatory disease
Proximal interphalangeal and metacarpophalangeal joints
Rheumatoid nodules at pressure points
Rheumatoid factor
Single or multiple joints
Painful synovial inflammation, swelling, and increased fluid
Morning stiffness
Symmetrical distribution of several joints
Fusiform swelling
Synovitis of temporomandibular joint
Affects nearly all joints
Except t-spine and lumbosacral spine
166
Rheumatoid Arthritis S/S Atlantoaxial subluxation
Atlantoaxial subluxation
Odontoid process protrudes into the foramen magnum
Pressure on the spinal cord or impairs vertebral artery blood flow
167
Rheumatoid Arthritis S/S Cricoarytenoid arthritis
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
168
Rheumatoid Arthritis S/S
Atlantoaxial subluxation
Cricoarytenoid arthritis
Osteoporosis
NM: Weakened skeletal muscles
-Peripheral neuropathies
CV: Pericarditis, accelerated coronary atherosclerosis
Pulmonary: Restrictive lung changes
Hematology: anemia, neutropenia, elevated platelets
Keratoconjunctivitis sicca and xerostomia
169
Rheumatoid Arthritis Treatment
NSAIDS
Decrease joint swelling, relieve stiffness, provide analgesia
COX-1 inhibitors, COX-2 inhibitors
Corticosteroids
Decrease joint swelling, pain, and morning stiffness
DMARDs (Disease-modifying antirheumatic drugs)- methotrexate
Tumor necrosis factor (TNF-alpha) inhibitors and interleukin (IL-1) inhibitors
Surgery
170
Rheumatoid Arthritis Anesthesia Management
Airway
-Atlantoaxial subluxation
-TMJ limitation
-Cricoarytenoid joints
Severe rheumatoid lung disease
Protect eyes
Stress dose
171
Systemic Lupus Erythematosus
Multisystem chronic inflammatory
Antinuclear antibody production
172
Systemic Lupus Erythematosus Typical manifestations:
Antinuclear antibodies
Characteristic malar rash
Thrombocytopenia
Serositis
Nephritis
173
Systemic Lupus Erythematosus S/S
Polyarthritis and dermatitis
Symmetrical arthritis
-No spinal involvement
-Avascular necrosis of femoral head or condyle
CNS: Cognitive dysfunction, psychological changes
CV: Pericarditis, coronary atherosclerosis, Raynaud’s
Pulmonary: Lupus pneumonia, restrictive lung disease, vanishing lung syndrome
Renal: Glomerulonephritis, decreased GFR
GI/Liver: ABD pain, pancreatitis, elevated liver enzymes
NM: Skeletal muscle weakness
Hematology: Thromboembolism, thrombocytopenia, hemolytic anemia,
Skin: Butterfly-shaped malar rash, discoid lesions, alopecia
174
Systemic Lupus Erythematosus Treatment
NSAIDs or ASA
Anti-malarial; Hydroxychloroquine and quinacrine
Corticosteroids
Immunosuppressants; Methotrexate, azathioprine
175
Systemic Lupus Erythematosus Anesthesia Management
Based upon manifestations and organ dysfunction
Airway: recurrent laryngeal nerve palsy, cricoarytenoid arthritis
Stress dose of corticosteroids
176
Malignant Hyperthermia
Hypermetabolic syndrome
Genetic mutation
-Ryanodine receptor - RYR1 gene
-Dihydropyridine receptor
Exposure to inhaled VA and succinylcholine
50% mortality
Family history
Uncontrolled elevation of sarcoplasmic calcium
Sustained activation of muscle contraction
Rhabdomyolysis
177
Malignant Hyperthermia S/S Early
hypercarbia
tachypnea (if respiration is spontaneous
sinus tachycardia
masseter muscle spasm
generalized muscle rigidity
Peaked T waves
metabolic and respiratory acidosis
178
Malignant Hyperthermia S/S Late
Hyperthermia
cola-colored urine/ rhabdo
elevated CPK
cardiac dysrhythmia
acute renal failure
cardiovascular collapse
DIC.
179
Malignant Hyperthermia Treatment
D/C all triggering gas/drugs
Hyperventilate with 100% O2 at 10 L/min
Change breathing circuit and soda lime
Dantrolene; 20 mg + 3 G mannitol, Mix with 60 mL sterile water
-Initial dose 2.5 mg/kg
-Max upper limit 10 mg/kg
Treat arrythmias
Monitor urine output
180
Malignant Hyperthermia Post-Op
Transfer to ICU 24-48 hours
Report to MH registry
MH testing for pt and family members
-Muscle biopsy contracture testing
--Halothane plus caffeine contracture test
