Highlights from Dr. Gegel's MS Lecture Flashcards by Dana Colclough

Primary presentation of RA

Pain and disability

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Role of cytokines in RA

TNF, IL-1, IL-6 are released and accelerates the inflammatory cascade

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Role of B lymphocytes in RA

Produce antibodies (Rheumatoid factor) that enhances cytokine production

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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

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NSAIDs for RA

Tx of inflammation

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Corticosteroids for RA

Blunt the immune response, but unable to slow the progression

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What type of medications are used to slow down the progression of RA?

DMARDS

Disease-modifying antirheumatic drugs

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What type of cells does DMARDS target

B and T cells

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Give an example of a DMARD

Methotrexate

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What labs should be checked preoperatively for a pt taking Methotrexate?

CBC and LFTs

Methotrexate (DMARD) is associated with pancytopenia and decreased liver fxn

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What are examples of TNF inhibitors used with RA?

Infliximab (Remicade)
Adalimumab (Humira)
Certolizumad pegol (Cimzia)

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The inhibition of TNF is a achieved by?

Monoclonal antibodies

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What is another option for RA tx?

Fusion protein such as Etanercept (Enbrel)

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T/F: Degree of cord compression may not correlate with pt’s symptoms.

True

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What type of radiograph is appropriate for pt’s with RA?

C-spine (lateral flexion and extension)

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Which type of anesthesia can be challenging for pts with RA?

Regional anesthesia

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What MS d/o is associated with “bamboo spine”?

Ankylosing Spondylitis

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What cardiac change can you expect in 40% of Anky Spond pts?

Aortic Valve Insufficiency

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What are renal effects seen with systemic lupus erythematosus?

Dialysis and renal transplant in 20% of pts

Renal involvement suggests poor prognosis

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Medications utilized in drug-induced lupus disease?

ACEI
Hydralazine
Procainamide
Methyldopa
Isoniazid (INH)

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What type of consult could you consider ordering for SLE (lupus) diagnostic testing?

Cardiology consult

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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

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Sclerosis lab exams are based on what?

H&P and preop medications

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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

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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