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Anesthesia 101 > ITE Neuro > Flashcards

ITE Neuro Flashcards

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1
Q

Name that pathway!

Peripheral nerve ->
Ipsilateral dorsal root ganglia ->
Ipsilateral posterior and lateral SPINAL CORD ->
Decussation (crossover) of nerve fibers at cervicomedullary junction ->
Contralateral medial lemniscus (w/in BRAINSTEM) ->
Contralateral ventroposterolateral nucleus of THALAMUS->
Contralateral thalamocortical radiation ->
Contralateral sensorimotor cerebral cortex

A

Pathway for Sensory Evoked Potentials (SSEPs)

- ascending pathway

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2
Q

Name that pathway!

Lower limb cortex ->
Internal capsule ->
Brainstem (decussate at medulla) ->
Corticospinal tract ->
Peripheral n.
A

Pathway for Motor Evoked Potentials (SEPs)

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3
Q

Name that pathway!

Retina ->
Optic n ->
Optic chiasm ->
Optic tract ->
Superior Colliculus ->
Visual cortex
A

Pathway for Visual Evoked Potentials (SEPs)

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4
Q

During multilevel spinal fusion, the ________ nerves are monitored so that the RIGHT side of the posterior spinal cord and LEFT brainstem and cortex can be assessed.

A

Right Median and Tibial nerves

*Neuronal cells along sensory pathway are at risk for surgical damage or ischemia

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5
Q

Ischemic changes in SSEPs are quantified by reduction in _____ of the signal strength and increase in its _______ (time to signal detection

A

amplitude

latency

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6
Q

________ is the most cost-effective, accurate, and reliable method of monitoring intracranial pressure.

A

Ventriculostomy catheter

- it also provides a way to drain CSF and samples for lab analysis

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7
Q

Noninvasive way to measure ICP

A

measuring optic nerve sheath diameter via ultrasound

- new, not standard

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8
Q 
Autonomic hyperreflexia (or autonomic dysreflexia) is a syndrome that may occur in pts with spinal cord injuries above the level of \_\_\_. 
This is usually seen at \_\_\_\_\_ (time) after spinal cord injury.
A

T12
- particularly above T5!

2 weeks - 6 months

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9
Q

Why does Autonomic hyperreflexia (or autonomic dysreflexia) occur?
- ie: reflex bradycardia, severe HTN, arrythmias, MI, intense vasoconstriction (cool, dry, pale skin below SCI)

A

It occurs d/t cutaneous or visceral stimulation below the level of the SCI, and inhibitory impulses from higher CNS centers cannot reach and no longer help regulate.
- there is reflex cutaneous vasodilation above lvl of SCI (nasal congestion, sweating, warm, flushed skin in UE)

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10
Q

Prevention of Autonomic hyperreflexia (or autonomic dysreflexia) is best done with ____

A

spinal or epidural anesthesia w/ local anesthetic and/or deep GA

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11
Q

Treatment of Autonomic hyperreflexia (or autonomic dysreflexia)

A

Stop triggering event

Administer fast acting direct vasodilators (sodium nitroprusside, nitroglycerin, or nicardipine)

*BB can worsen reflexive bradycardia if given in setting of unopposed a-stimulation -> hypertensive crisis

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12
Q

What is the receptor theory of muscle relaxants? What is the responses/sensitivities thought to be d/t?

A

Upregulation of receptors is associated with :
HYPERsensitivity to agonists (succinylcholine) and
HYPOsensitivity to antagonists (rocuronium)

Thought to be d/t presence/absence of an isoform of AChR that develop after denervation or burn injuries

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13
Q

Mature postjunctional AChRs are composed of what subunits?

What do immature isoforms of AChR look like that only form after denervation or burn injuries?

A

5 subunits

  • 2 a1
  • B1
  • delta
  • epsilon

Isoform: (Immature upregulated receptors)
7 subunits
- 2a1B1dy

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14
Q

Why does succinylcholine admin in the presence of upregulated AChRs (ie. denervation or burn injuries) result in potentially lethal hyperkalemia?

A

The whole muscle membrane depolarizes ->
Massive efflux of potassium from cell

*Succinylcholine is a molecule closely resembling ACh

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15
Q

The parasympathetic component of the facial (VII), glossopharyngeal (IX), and vagus nerves (X) lie in the _______ (structure).

A

Medulla oblongata (of brainstem)

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16
Q

The parasympathetic component of the oculomotor nerve (III) lie in the _______ (structure).

A

midbrain (of brainstem)

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17
Q

Which cranial nerve has the most extensive distribution of the PNS?

A

Vagus nerve X

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18
Q

Full-flow CPB is maintained for ____ min after reaching goal temperature to ensure ____

A

20-30

adequate cerebral cooling prior to stopping circulation

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19
Q

Pts with ALS have high risk of having pulmonary complications d/t ______ involvement and respiratory muscle weakness.
- How does management change for succinylcholine vs roc?

A

bulbar muscle

Avoid sux

  • ALS assoc. w/ LOSS of motor neurons, forming extrajunctional ACh receptors and can mount exaggerated response
  • life threatening hyperK

Lower dose of Roc

  • higher sensitivity, prolonged, exaggerated response
  • upregulation of extrajunctional receptors on postsynaptic neurons
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20
Q

Normal ICP is ___ mmHg.

Elevated is ____ mmHg

A

5-15 mmHg

20 mmHg

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21
Q

MAC of nitrous oxide is ___

A

105%

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22
Q

How does nitrous oxide cause increase in ICP?

A

Increase in:

  • cerebral metabolic rate
  • cerebral blood flow
  • can diffuse into air filled cavities
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23
Q

Intracranial space has 3 major components, and any changes to ICP can be made by altering them.

A
  1. Brain parenchyma
  2. Blood
  3. CSF
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24
Q

How do propofol, thiopental, and etomidate affect ICP?

A

All

  • decrease ICP
  • decrease Cerebral metabolic rate of O2 (CMRO2)
  • decrease CBF

*opioids have little to no effect on CBF

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25
Q

How does ketamine affect ICP?

A

No effect on CMRO2

Marked cerebral vasodilation ->
Increase ICP

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26
Q

When hyperventilating to decrease ICP (hypocarbic vasoconstriction of cerebral vessels), what is your target PaCO2?

A

25-35 mmHg

*any lower, you can cause local ischemia

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27
Q

The spinal cord receives 75% of its blood supply from ______ artery, and 25% of its blood supply from the ____ artery. Which one provides the motor and which one the sensory tract?

A

anterior spinal artery
- motor tracts

2 posterior spinal arteries
- sensory tracts

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28
Q

The anterior spinal artery receives most of its blood flow from the anterior radicular arteries in the thoracic segment of the spinal cord. The largest radicular artery is the _____

A

artery of Adamkiewicz

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29
Q

Why is hyperventilation during endovascular aneurysm coiling avoided?

A

hypocarbic vasoconstriction of cerebral vessels -> coils can end up in vessels rather than target aneurysm (improper coil placement)

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30
Q

In pts with myasthenia gravis, how does management change for succinylcholine vs roc?

A

Increase dose of sux
- more resistant to sux d/t decrease in total # of functioning receptors (smaller number of AChRs available for depolarization) and impaired plasma cholinesterase function

Lower dose of Roc
- higher sensitivity, exaggerated response

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31
Q

In pts with lambert-eaton myasthenic syndrome, how does management change for succinylcholine vs roc?

A

Lower dose of sux

  • higher sensitivity d/t destruction of presynaptic VGCC -> decrease in release of ACh from nerve terminals, less competition
  • (note: No receptor upregulation)

Lower dose of Roc
- higher sensitivity, exaggerated response

  • Lambs are sensitive animals
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32
Q

Myasthenia gravis is caused by antibodies against _____

Lambert Eaten is caused by antibodies against _____

A

postsynaptic ACh receptor (80%) or Muscle specific tyrosine kinase MuSK-Ab (20%)

P/Q-type voltage gated calcium channels

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33
Q

Acute and chronic phenytoin use affecting nondepolarizing NMBs

A

acute: potentiates blockade
chronic: increases resistance

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34
Q

Volatile agent effects on cerebral blood flow

A

Opposing effects:

  1. Decrease CMRO2
  2. Increase CBF (cerebral vasodilation)
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35
Q

Why does methemoglobin cause hypoxia?

A
  • Methemoglobin (MetHb) is an altered state of Hb where the Ferrous (Fe2+) form of heme is oxidized to Ferric (Fe3+).
  • MetHb does not bind O2 and therefore cannot transport it for use
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36
Q

What value is falsely elevated in methemoglobin and what value will rise when you administer oxygen?

A

SpO2 falsely elevated since it is calculated based on the assumption that all hb is normal

PaO2 will increase appropriately since it is unaffcted by MetHb

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37
Q

General anesthetic effects on the brain resemble _____, with an EEG that shows _____

A

Naturally occuring non-rapid eye movement (NREM) sleep

EEG

  • Slow frequency
  • Large amplitude
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38
Q

EEG in an awake individual

A

Fast frequency

Low amplitude

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39
Q

EEG in REM sleep

A

Fast frequency

Low amplitude

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40
Q

Most common causes of atlantoaxial instability

A
  1. Trauma
  2. Achondroplasia
  3. Down syndrome
  4. RA
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41
Q

Least accurate measure of core body temp?

A

Bladder

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42
Q

Most common cause for a subarachnoid hemorrhage pt to lose consciousness during the first day of hospitalization

A

rebleeding

most common cause of death from SAH:
- first bleed
Second most common
- rebleed

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43
Q

Most common cause for a subarachnoid hemorrhage pt to lose consciousness 5-10 days out from surgery

A

vasospasm

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44
Q

Why is an opioid only spinal inadequate for a pt with a spinal cord injury?

A

Does not prevent autonomic hyperreflexia

-

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45
Q

Best sedation for deep brain stimulation placement

A

dexmedetomidine (alpha 2 agonist)

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46
Q

What meds should be avoided during deep brain stimulation placement?

A

Gabaminergic meds

- interferes with microelectrode recording (MER) and mapping for electrode placement

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47
Q

Parkinson disease is caused by loss of _____ neurons in the ______

A

dopamine-secreting neurons

substantia nigra of basal ganglia

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48
Q

_____ is the first line tx in pt with organophosphate poisoning

A

Atropine
- antagonize action of ACh at the muscarinic synpases

(or pralidoxime)

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49
Q

The main effect of organophosphates is to ______

A

inhibit acetylcholinesterase (AChE) and butyrylcholinesterase in the cholinergic nervous system

*end result is stimulating muscarinic synapses

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50
Q

Signs and symptoms of organophosphate poisoning

A

SLUDGE Mi

Salivation
Lacrimation
Urination
Defecation
Gi motility
Emesis
Miosis
51
Q

In an awake craniotomy, a sz is caused by _____, and administration of propofol or (warm/iced) saline is first line of action

A

cortical stimulation

iced

52
Q

Difference btwn Duchenne and Becker muscular dystrophy?

A

Duchenne: no dystrophin

Becker: decreased quantity of dystrophin

53
Q

Pts in the _______ position who undergo posterior fossa or cervical dural incisions are at the highest risk for developing a clinically significant pneumocephalus

A

seated

54
Q

What is Cushing’s Triad?

A

HTN
Bradycardia
Decreased RR

*sign of increased ICP

55
Q

_________ is the best diagnostic tool to diagnose cerebral vasospasm after a subarachnoid hemorrhage

A

cerebral angiography

56
Q

Vasospasm after SAH can occur ___ days after, and peaks at ____ days. Spasms typically resolve by day ____

A

3

6-10

14

57
Q

Treatment for vasospasm following SAH

A

Triple H

  1. Hypervolemia
  2. Hypertension
  3. Hemodilution
58
Q

When diagnosing brain death, _____ reflexes are permissible, and _____ reflexes are not

A

spinally-mediated
- patellar reflex

Brainstem

  • light
  • occulocephalic
  • vestibular
  • corneal
  • facial
  • pharyngeal (gag)
  • tracheal (cough)
59
Q

Myasthenia gravis vs lambert eaton

- which one is alleviated with movement?

A

Lambert eaton (myasthenic syndrome)

60
Q

Transmural pressure equation

A

MAP - ICP

TMP of an aneurysm determines risk of rupture

*decrease in CSF will increase transmural pressure and can lead to aneurysm rupture

61
Q

What are ECG changes during SAH d/t?

A

High circulating catecholamines ->

subendocardial ischemia

62
Q

GCS score

A

Motor (6)
Verbal (5)
Eyes (4)

63
Q

Metabolic (acidosis/alkalosis) exacerbates hypokalemia by _____

A

alkalosis

Intracellular H+ gets transported out of cell and K+ into cell ->
creating intracellular shift of potassium

64
Q

Metabolic (acidosis/alkalosis) exacerbates HYPERkalemia by _____

A

Acidosis

H+ gets transported into cell and K+ out of cell ->
creating extracellular shift of potassium

65
Q

Mothers with myasthenia gravis who are giving birth, need to have their infants monitored for _____ (time) after birth d/t maternal antibodies to _______ freely crossing placenta

A

24-48 hours after birth

acetylcholine receptors in postsynaptic neuromuscular junction
- Transient Neonatal Myasthenia Gravis (TNMG)

66
Q

Treatment for infants with Transient Neonatal Myasthenia Gravis (TNMG)

A

Acetylcholinesterase inhibitors

Nutritional and respiratory support

67
Q

The basilar artery of the circle of willis splits into ____

A

2 posterior cerebral arteries

68
Q

The anterior inferior cerebellar artery of the circle of willis branches off of the ______ artery

A

basilar

69
Q

The internal carotid of the circle of willis branches into ______

A

Middle and anterior cerebral arteries

70
Q

For ALS, MG, and Lambert Eaton, how do you titrate rocuronium?

A

Lower dose of Roc

- higher sensitivity, prolonged, exaggerated response

71
Q

Why is neuraxial anesthesia relatively contraindicated in ALS?

A

Lack of protective n sheath around spinal cord and demyelination makes spinal cord more susceptible to potential neurotoxic effects of LA
- if you have to, epidural > intrathecal

72
Q

For ALS, MG, and Lambert Eaton, how do you titrate succinylcholine?

A

ALS
Avoid sux
- life threatening hyperK

Lambert Eaton:

  • Lower dose of sux
  • slighly more sensitive to

MG:
Increase dose of sux
- more resistant to

73
Q

Most common cause of SAH is ______.

A

Ruptured cerebral aneurysm

74
Q

Modified Hunt-Hess scale of grading SAH

A

0-5, progressively getting worse

0 - unruptured aneurysm
5 - Coma, decerebrate posture

75
Q

Calcitriol

  • What does it do?
  • Where does it act?
A

Active form of Vit D

  • Increases GI uptake of Ca2+
  • Decreases renal Ca2+ excretion
76
Q

What hormones are Secreted in the posterior pituitary?

A

ADH

Oxytocin

77
Q

Bromocriptine and cabergoline are _____, and act as a negative feedback NT for the production of ______ in the anterior pituitary

A

Dopamine agonists

Prolactin

78
Q

Why are pts with acromegaly d/t GH secreting tumor considered difficult airways? (5)

A
  1. Smaller size of glottic opening
  2. Hypertrophy of aryepiglottic folds
  3. Calcinosis of larynx
  4. Recurrent laryngeal n injury
  5. Hypertrophy of tongue
79
Q

Pts with panhypopituitarism d/t pituitary tumor are generally prescribed _____ preoperatively

A
  1. Glucocorticoids
    - brain swelling
    - suppressed adrenal axis from ACTH insufficiency
  2. Vasopressin
    - lack of ADH
  3. Thyroxine
80
Q

Hyperkalemic periodic paralysis is a _______caused by _____

A

hereditary skeletal muscle ion channelopathy that causes MYOTONIC paralysis

VG-sodium channel defects
*same as Type 2 Hypokalemic Periodic paralysis but is hyperexcitable

81
Q

Hypokalemic periodic paralysis is a _______caused by _____

A

hereditary skeletal muscle ion channelopathy that causes FLACCID paralysis that affects proximal muscles, limbs, trunks, respiratory m weakness

Type 1: calcium channel defect
Type 2: Sodium channel
- less functional

82
Q

Myotonia congenita is a _______ channelopathy that is characterized by ____

A

chloride channel skeletal muscle

“warm up effect”
- muscle stiffness worsens after rest, improves with use

83
Q

What is most effective at decreasing incidence of myalgia

A

preop NSAIDs

84
Q

Clinical manifestations of Myasthenia Gravis vs Lambert Eaton (myasthenic syndrome)

  • Muscle weakness location
  • Muscle strength with movement/exercise
  • Reflexes absent/present
  • Muscle pain common/uncommon
A

Myasthenia gravis

  • Extraocular, bulbar, facial
  • Muscle strength worsens with movement/exercise
  • Reflexes normal
  • Muscle pain uncommon

LE

  • Proximal limb
  • Muscle strength improves with movement/exercise
  • Reflexes decreased/absent
  • Muscle pain common
85
Q

Myasthenia Gravis vs Lambert Eaton (myasthenic syndrome)

- Response to anticholinesterase

A

Myasthenia Gravis:
- Good response

Lambert Eaton (myasthenic syndrome)
- Poor response
86
Q

Are children at high risk of post-op delirium?

A

Yes, extremes of age

- 30% in peds pt

87
Q

What types of surgeries are at high risk of post op delirium?

A

Cardiac
Thoracic
Orthopedic (hip)

88
Q

Limb-girdle muscular dystrophy causes weakness of proximal muscles and _______ that can lead to short life span.

A

Cardiomyopathy and AV conduction defects

89
Q

Why should volatile anesthetics and succinylcholine be avoided in Limb-girdle muscular dystrophy?

A

Risk of rhabdo

Hyperkalemia

90
Q

Why is using succinylcholine a bad idea in pts with prolonged use of NMB agents?

A

acetylcholine receptor upregulation -> inc sensitivity to succ -> hyperK

91
Q

What predicts a decrease likelihood that postop mechanical ventilation is required in Myasthenia gravis pts?

  • Disease for < ___ months,
  • pyridostigmine dose > __ mg/d
  • a vital capacity of ___L
A
  • 72 months*
  • 6 years (greatest risk)

> 750 mg/day

< 2.9 L

92
Q

In a normotensive pt with increased ICP and PCO2 of 25 mmHg, the quickest way to reduce ICP is ____

A

propofol

93
Q

Hoarseness following anterior cervical spinal cord surgery is most commonly d/t ____

A

vocal cord palsy (VCP)

- d/t direct pressure of ETT on recurrent laryngeal n during surgical retraction

94
Q

In pts with mitochondrial myopathies (impairment in oxidative phosphorylation), you need to assess preop baseline function in: (4)

A
  1. Hypotonia
  2. Neuro function
  3. Multi organ dysfunction
  4. Cardiomyopathy
95
Q

In pts with mitochondrial myopathies (impairment in oxidative phosphorylation), you need to minimize what stressors: (6)

A
  1. Prolonged fasting
  2. Hypoglycemia
  3. Hypothermia
  4. Tourniquet use
  5. N/V
  6. Anxiety
96
Q

What is the “wake up” test?

A

Discontinuing or decreasing anesthetics to facilitate pts being able to follow commands

  • Assess gross motor function -> Ask pts to move UE, then LE
  • “All or nothing”
  • If pt is able to do this, unlikely to have spinal cord compromised
  • Then you re-apply rapidly active sedative (prop)
97
Q

What is more concerning, decerebrate (extension) or decorticate (flexion) response to pain?

A

Decerebrate (extension)

- most people will withdraw to pain

98
Q

Motor GCS

A 
1 - no response
2 - Decerebrate (extension)
3 - Decorticate (flexion)
4 - Withdrawl from pain
5 - Localizes painful stimulus
6 - obeys commands
99
Q

Verbal GCS

A
  1. No response
  2. Incoherent sounds
  3. Incongruent WORDS
  4. Confused speech
  5. Normal convo
100
Q

Why should mannitol be given slowly over 10-15 min to reduce ICP?

A

Can paradoxically cause a vasodilatory effect -> engorgement of brain -> inc ICP

101
Q

Why is succinylcholine bad for pts with Multiple SCLEROSIS and a recent spinal cord transection?

A

Upregulation of nicotinic ACh receptors –> hyperkalemia

102
Q

How does succinylcholine work?

A

2 molecules of ACh linked by a methyl group
- stimulates ACH receptors at NMJ ->
Opens ion channels and cause depolarization

Then degraded by plasma cholinesterase or pseudocholinesterase
(not degraded by acetylcholinesterase)

103
Q

How do all volatile anesthestics affect:

  • CMRO2
  • CBF
  • ICP
A
  • CMRO2: decrease (with seep)
  • CBF: increase (d/t vasodilation in dose dependent manner)
  • ICP: increase
104
Q

The brain uses ___% of the total body’s oxygen consumption

A

20%

105
Q

How does Propofol, etomidate, Benzo and thiopental affect:

  • CMRO2
  • CBF
  • ICP
A
  • CMRO2: decrease
  • CBF: decrease
  • ICP: decrease
106
Q

Neostigmine reverses paralytic how?

A

Anticholinesterase that reverses nondepolarizing neuromuscular blockers
- prevents destruction of ACh -> potentiate ACh at receptors

*glycopyrrolate is anticholinergic agent

107
Q

Why is deliberate hypotension performed at the time of embolization of AVMs?

A

Decrease flow of blood through the artery that feeds the AVM and prevent systemic embolization of the endovascular glue that is used

108
Q

How long to pts with AVMs anticoagulated for periop?

A

at least 24h post op to prevent thrombus development

109
Q

Parasympathetic stimulation of heart causes (depolarization/hyperpolarization) of the heart

A

Hyperpolarization

- efflux of potassium out of cell -> slow conduction -> decrease SA and AV node conduction

110
Q

How can ketamine induce seizures? (4)

A
  1. Increase CMRO2
  2. Increase CBF
  3. Lower sz threshold
  4. Stim CNS
111
Q

Serotonin syndrome presentation (6)

A
  1. HTN
  2. Hyperthermia
  3. Tachycardia
  4. Tremors
  5. Overactive reflexes
  6. Muscle rigidity
112
Q

What spinal pathway tract carries fine touch and proprioception?

A

Dorsal column (posterior column) travels through

  • Gracile faciculus -> nucleus
  • Cuneate faciculus -> nucleus
113
Q

What spinal pathway tract carries limb motor ?

A

Lateral corticospinal tract

114
Q

What spinal pathway tract carries pain and temp?

A

Lateral spinothalamic tract

115
Q

What spinal pathway tract carries crude touch?

A

Anterior spinothalamic tract

116
Q

What spinal pathway tract carries axial motor?

A

Ventral corticospinal tract

117
Q

What test differentiates CSF from normal saline (ie. during an epidural)

A

POC glucose test strip

- glucose is in CSF and not NS

118
Q

SSEP are a poor monitor for detecting vascular compromise of which arterial blood supply?

A

Anterior spinal artery

- supplies anterior MOTOR portion of the spinal column

119
Q

Fluid resuscitation in TBI pts

A

normal saline or hypertonic saline

  • Increasing MAP while decreasing ICP
  • hyperosmolar solns
120
Q

What type of solutions should be avoided in neurosurgery?

A

Glucose containing solns (ie: D5)

- worsens cerebral edema

121
Q

Cerebral vasospasm is a large cause of post-subarachnoid hemorrhage
- how do you treat it?

A

Triple H therapy

  1. Hypertension
  2. Hemodilution
  3. Hypervolemia

*increases perfusion past the spasm

122
Q

Jugular venous oximetry (SjvO2) is a measure of _____, which is done by placing a catheter in the jugular vein at _____ level

A

global oxygenation and perfusion

C1-C2

123
Q

Summary of Nervous system changes with aging: (5)

A
  1. Decreased gray/white matter
  2. Decreased NTs (ACh, dopamine)
  3. Decreased epidural space
  4. Decreased CSF volume
  5. Increased permeability of dura mater

Anesthesia 101 (38 decks)

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