Highlights from Dr. Gegel's MS Lecture Flashcards
Primary presentation of RA
Pain and disability
Role of cytokines in RA
TNF, IL-1, IL-6 are released and accelerates the inflammatory cascade
Role of B lymphocytes in RA
Produce antibodies (Rheumatoid factor) that enhances cytokine production
RA and C-spine relationship
The upper cervical spine is affected in 85% of patients which can result in Atlanto-axial subluxation and spinal cord compression
NSAIDs for RA
Tx of inflammation
Corticosteroids for RA
Blunt the immune response, but unable to slow the progression
What type of medications are used to slow down the progression of RA?
DMARDS
Disease-modifying antirheumatic drugs
What type of cells does DMARDS target
B and T cells
Give an example of a DMARD
Methotrexate
What labs should be checked preoperatively for a pt taking Methotrexate?
CBC and LFTs
Methotrexate (DMARD) is associated with pancytopenia and decreased liver fxn
What are examples of TNF inhibitors used with RA?
Infliximab (Remicade)
Adalimumab (Humira)
Certolizumad pegol (Cimzia)
The inhibition of TNF is a achieved by?
Monoclonal antibodies
What is another option for RA tx?
Fusion protein such as Etanercept (Enbrel)
T/F: Degree of cord compression may not correlate with pt’s symptoms.
True
What type of radiograph is appropriate for pt’s with RA?
C-spine (lateral flexion and extension)
Which type of anesthesia can be challenging for pts with RA?
Regional anesthesia
What MS d/o is associated with “bamboo spine”?
Ankylosing Spondylitis
What cardiac change can you expect in 40% of Anky Spond pts?
Aortic Valve Insufficiency
What are renal effects seen with systemic lupus erythematosus?
Dialysis and renal transplant in 20% of pts
Renal involvement suggests poor prognosis
Medications utilized in drug-induced lupus disease?
ACEI
Hydralazine
Procainamide
Methyldopa
Isoniazid (INH)
What type of consult could you consider ordering for SLE (lupus) diagnostic testing?
Cardiology consult
T/F: Acute renal failure occurs in about >50% of systemic sclerosis pts.
True.
ARF occurs in about 5% of pts characterized by fulminant acute-onset kidney injury, severe hypertension, and normal sediment.
Steroid therapy and pregnancy are associated w/ higher incidence of AFR
Sclerosis lab exams are based on what?
H&P and preop medications
Anesthesia implications of Sclerosis
Keep patient warm
Difficult IV access
Potential for airway difficulty
A-line placement carries higher risk d/t poor circ
VTE is 3x more common
List airway considerations regarding sclerosis anesthetic implications
Thorough airway exam
Potential airway difficulty
Consider video laryngoscope or FOB
Inc risk asp -> GI prophylaxis
What is the leading cause of lower extremity disability?
Osteoarthritis
Review OA &RA skeleton
With Kyphoscoliosis ________ cases are iodiopathic >80%
Most
What test measures to severity of Kyphoscoliosis?
Cobb angle
Cobb angle scale
15-20 degrees: no specific treatment
20-40 degrees: back brace
40-50 degrees of more: May require corrective sx (spinal fusion)
Airway consideration for pts with Kyphoscoliosis
Plan for difficult intubation!
Bring friends to the party!
What is a ependymoma?
A tumor from the ependyma (CNS), neurofibromatosis type II
Pediatric=intercranial, common in 4th ventricle
Adult=Spinal
Syringomyelia is caused by ependymoma
The ataxia of ______ ataxia results from the degeneration of nervous tissue in the ________, through connections with the _______, that leads to nerve cells to loose ________. (Kyphoscoliosis)
Friedreich’s; spinal cord, cerebellum, myelin sheath
What are the 3 types of connective tissue d/0?
Osteogenesis Imperfecta (OI)
Marfan Syndrome
Ehlers- Danlos Syndrome (EDS)
2 types of Osteogensis Imperfecta
Ol congenita
Ol tarda
Description of Ol congenita
Fractures occur in utero, death occur during perinatal period
Description of Ol tarda
Children or early adolescence with present of blur sclera, fractures from trial trauma, kyphoscoliosis, bowing of femur and tibia, otosclerosis progressing to deafness
Osteogenesis imperfecta anesthesia implications
Mild hyperthermia intraop, but it not a forerunner of malignant hyperthermia
Which connective tissue d/o has a high risk of aortic dissection?
Marfan Syndrome
What should be done in the intraop period to decrease the risk of aortic dissection?
Avoid any sustained increased in systemic blood pressure that may occur during DL or in response to painful surgical stimulation.
When the diameter os the ascending aorta exceeds 4.5 cm and substantial aortic regurgitation is present, what surgery is indicated?
Surgical replacement of the aortic valve and ascending aorta. This requires circ arrest!!!!
MS disease affects which system, CNS or PNS?
CNS
Clinical manifestations of MS are……?
Multifocal and always progressive
What should you avoid with patient’s with MS?
Avoid hyperthermia!!!!
This may cause exacerbation of MS
What type of block has been implicated in postoperative exacerbation of MS?
Spinal Anesthesia Blocks (SAB)
What med should be avoided with ALS?
Succinycholine.
D/t massive release of K
Categories of Seizure d/o
Focal (partial)
Generalized
Unknown
Simple
Complex
Focal seizures description
Focal (partial) seizures are neural discharges originating from one part of the cerebral hemisphere
With the following features: aura, motor, autonomic, dyscognitive
W/o dyscognitive features
Generalized seizures description
Arise from both hemispheres
Tonic clonic, Absence, Clonic, Tonic, Atonic, Myoclonic
Simple seizures description
No loss of consciousness
Complex seizures description
Altered level of consciousness
What med should you avoid in pts having an active seizure?
NMB
The patient may be paralyzed, but the seizure is still happening in the brain
Consideration for seizure meds and anesthetics
Anti-seizure meds have sedative properties and are liver enzyme-inducers
T/F: AED are enzyme inducers (CYP 450)
True.
You have to give more anesthetics because they are being broken down quicker due to the enzyme
Which inhalation agents provoke seizure-like activity?
Sevoflurane>isoflurane>desflurane
Which drugs should you avoid for seizure patients?
Avoid Ketamine, Methohexital, Etomidate, Meperidine, Atracurium
These meds lower the seizure threshold!!!!!
Which NM disease has antibodies that attack the postsynaptic ACh receptor at the NMJ
Myasthenia Gravis
Myasthenia Gravis muscle description
Proximal muscle weakness alleviated by rest, exacerbated by activity
Osserman Staging System classification is used in which NM d/o?
Myasthenia Gravis
Bulbar muscles are affected with Myasthenia Gravis, what happens with this dysfunction?
Bulbar muscles of the mouth and throat responsible for speech and swallowing
Myasthenia Anesthesia Implications
1) The effect of nondepolarizing NMB agents INCREASED SENSITIVITY
2) The effect of depolarizing NMB agents (SCh) is reduced, more RESISTANT, yet duration prolonged
What is the role of sugammadex in Myasthenia Gravis pts?
Safe to use
Myasthenia Risk for Post-operative Ventilation
Duration >6 years (12pts)
History of chronic respiratory disease (10pts)
Pyridostigmine dosage >750 mg/day (8pts)
Vital capacity < 2.9L (4pts)
Total score > 10 pts indicates increased risk for postoperative ventilation for at least 3hrs
The Lambert-Eaton Syndrome is associated with which NM disease?
Myasthenic Syndrome
What occurs during the Lamber-Eaton Syndrome?
Antibodies attack PRESYNAPTIC VOLTAGE-GATED CA CHANNELS ON NERVE TERMINALS
Describe what happens to muscle weakness in Lambert-Eaton Syndrome
Weakness improves throughout day with repeated nerve stimulation
List perioperative complications of Duchenne and Becker muscular dystrophies
Rhabdomyolysis
Hyperkalemia
MH
Cardiac arrest
What medications should be avoided in Muscular dystrophies?
Avoid Succinylcholine!!!!!
Severe Hyperkalemia, dysrhythmias, rhabdomyolysis
What is the 2nd type of medication that should be avoided with Muscular dystrophies?
Avoid MH triggering agents!!!!!!
Hypermetabolic syndrome with SCh and halogenated inhalation anesthetics
Severe hyperkalemia, dysrhythmias, rhabdomyolysis
Anesthetic plan???
T/F: Unpredictable responses to anesthetic agents are common in MMD (Myotonia and Myotonic Dystrophy). Be judicious!!!
True
Over ______% of perioperative strokes occur in the post-op period.
80%
What should be determined in preop for a dementia patient?
Neurologic baseline/level of cognitive dysfunction
Caution should be used with what types of medication for which types of patients?
Benzos
Antihistamines
Anti-cholinergics (Atropine and scop)
What surgical treatment is performed for patients with Parkinson’s disease?
Deep brain stimulation
Targets areas w/i the basal ganglia
T/F: Parkinson medications should continued the DOS?
True!!!!!
What medications should be avoided in patient’s with Parkinson’s disease?
Avoid dopamine antagonists
1) Reglan
2) Inapsine
3) Phenergan
Anesthesia implications of embolization treatment
1) Maintain hemodynamics and NMB!!!!!
2) Hemodynamics should be optimized to avoid rupture, re-bleeding, and cerebral ischemia
3) No movement
Where do primary adenomas occur?
Adenohypophysis
