Memory Master Test 4

Question 1

3 major concerns related to anesthetizing Down’s patients?

Answer 1

1) Intubation may be difficult owing to LARGE TONGUE, SHORT NECK, SMALL MOUTH, AND SUBGLOTTIC STENOSIS. 1 ETT size smaller
2) Neck flexion during laryngoscopy and intubation may result in atlanto-occipital dislocation because of congenitally weak ligaments (consider getting cervical-spine films)
3) CONGENITAL HEART DISEASE is present in 40% of patients.

Question 2

VATER syndrome

Answer 2

Vertebral anomalies
Anal or intestinal atresia
Cardiac Anomalies
Tracheo-
Esophageal fistula
Renal Malformations
Limb abnormalities

Question 3

At what age is cleft palate usually repaired?

Answer 3

12-18 months

Question 4

What are eleven clinical manifestations of MH?

Answer 4

1) Tachycardia
2) Tachypnea
3) Hypercarbia
4) Hyperthermia
5) Hypertension
6) Hyperkalemia
7) Hypoxemia
8) Acidosis (metabolic)
9) Myoglobinuria
10) Cardiac dysrhythmias
11) Skeletal muscle rigidity
MATTCHHHHHS

Question 5

Earliest Sign of MH?

Answer 5

Increased ETCO2

Question 6

How fast does temp increase during MH?

Answer 6

1-2 C q 5min

Question 7

Diagnostic test for MH?

Answer 7

Halothane-caffeine contracture test is standard

Question 8

How is MH diagnostic test done? Is it sensitive?

Answer 8

Skeletal muscle biopsy is placed in solution of halothane. Sustained contraction of muscle in response to halothane is diagnostic.

Test is not very sensitive. Many false +’s

Question 9

Identify the anesthetic agents that are absolutely contraindicated in the patient with family history of MH?

Answer 9

Volatile inhalation agents and succs

Question 10

8 actions for initial MH management

Answer 10

1) D/C inhaled volatiles and succs
2) Hyperventilate with 100% O2
3) Dantrolene (Ryanodex or Dantrium)
4) Treat acidosis with bicarb (1-2 mM/kg)
5) Lower body temp to 38C with ice packs/gastric lavage
6) place CHARCOAL filters, new anesthetic circuit, new CO2 absorber
7) monitor with capnography and blood gas
8) if necessary, treat hyperkalemia and dysrhythmias.

Question 11

A patient just experienced masseter muscle rigidity from succinylcholine. What lab confirms diagnosis of MH?

Answer 11

Increased in creatine phosphokinase (CPK> 20,000)

Question 12

How and where does dantrolene work?

Answer 12

Dantrolene acts at the ryanodine receptor to decrease the calcium level in the skeletal muscle cell by decreasing the release of calcium from Sarcoplasmic Reticulum.

Skeletal muscle relaxes when the supply of Ca to the contractile proteins is impaired.

Question 13

List 4 ways to actively cool the patient during an acute episode of MH

Answer 13

1) Lavage (orogastric, urinary bladder, open cavities)
2) Administration of chilled IV NS
3) Cardiopulmonary bypass in severe cases
4) Surface cooling (icepacks to groin, axilla, neck, forced air)

Question 14

What body temp should cooling of MH patient be stopped? Why?

Answer 14

Core temp 38C to prevent deleterious effects of hypothermia

Question 15

Once the initial episode of MH is controlled, the patient will remain at risk for what 5 complications?

Answer 15

1) Reoccurence
2) DIC
3) Myoglobinuric renal failure
4) Skeletal muscle weakness
5) Electrolyte abnormalities

DREMS

Question 16

A patient with MH crisis has PVCs. What is drug of choice?

Answer 16

Procainamide 15mg/kg IV

Lidocaine also acceptable

Question 17

A woman in labor is identified as being susceptible to MH. What anesthetic techniques are acceptable?

Answer 17

Epidural without dantrolene pretreatment for routine labor. If general anesthesia is selected administer dantrolene prophylactically and use non-triggering agents.

Question 18

During preop assessment of the patient you discover a + family history of MH. What six steps need to be taken to manage this patient? Are non depolarizers safe for the patient?

Answer 18

1) Anesthesia and premedication should be designed to produce low normal HR. Opioids benzos barbs antihistamines anticholinergics do not cause problems in MH
2) anesthesia machine has volatile vaporizers removed and changing CO2 absorbant and flush O2 at 10L/min for >10min
3) Measure ETCO2
4) Body core temp (Nasal, rectal, esophageal) If not possible IV induction follwed by N2O O2 and non depolarizers with opioids. Versed, precedex, diazepam, droperidol, and propofol are safe in MH
5) Art and CVL recommended only as dictated by surgical procedures
6) Observe patient closely Post OP

Question 19

Why might 2.5 mg/kg dantrolene be administered to patient preoperatively?

Answer 19

Prevent MH

Question 20

What syndrome mimics MH?

Answer 20

Neuroleptic Malignant Syndrome

NMS develops over 24-72 hrs / MH acutely develops

NMS presents as hypermetabolic episode consisting of hyperthermia, autonomic nervous system instability, muscle rigidity, and rhabdomyolysis

Question 21

Child undergoing surgery with halothane develops tachycardia, increased temp, skeletal muscle rigidity. Drug of choice?

Answer 21

Dantrolene2.5 mg/kg

Question 22

Halothane-caffeine contracture test. Good for MH? Why or why not?

Answer 22

No good. Too many false +’s

Question 23

Which drugs should be avoided in the patient with a family history of MH?

Answer 23

Succinylcholine and volatile agents

Question 24

Patients treated with what drugs are susceptible to neuroleptic malignant syndrome (NMS)?

Answer 24

NMS results from treatment with antipsychotic agents, (like phenothiazines, haldol, etc).

NMS following antipsychotic drug therapy presumably reflects dopamine depletion in the CNS