MSK Flashcards by Ashley Mueller

Diagnosis of Lupus is usually confirmed with 3 of the 4 typical manifestations which are?

antinuclear antibodies
rash
thrombocytopenia 
serositis
nephritis

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what is the number one death of patients with lupus? and what does this mean for anesthetic concerns?

atherosclerosis d/t long term steroid use… be sure to give stress dose of steroids pre-op

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What are some of the treatments for Lupus? and how may they affect your anesthetics?

NSAIDS- bleeding
Anti-malarials - decrease immune response
IV gammaglobulin
Immunosuppresive tx (cyclophosphomide) inhibits plasma cholinesterase –> prolongs succ

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Anesthetics considerations for the patient with lupus?

what drugs are they on?

related organ dysfunc? (renal bun/cr, cardiopulm, hepatic clearance of drugs, CNS-> SZR stroke, neuropathies)

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Lupus pre-induction, induction and airway mgmt?

preinduction: steroids monitoring infection stress of surgery positioning
induction: myocardial spearing drugs, NMB that are renal safe
Airway: if cricoarytenoid arthritis need a smaller ETT
mucosal ulceration
recurrent Laryngeal Nerve Palsy -aspiration risk

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Drugs to avoid in Lupus?

Meperidine
Thiopental
Methohexital 
d-tubo
metocurine
pancuronium
gallamine
**also single dose is fine but avoid repeat dose of morphine active metabolite

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Rheumatoid Arthritis has axial involvement in what portion of the spine? is regional anesthesia acceptable?

involvement is in the upper cervical spine only so lumbar placement is acceptable

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Anesthetic considerations for the patient with rheumatoid arthritis ?

Airway is biggest concern --> TMJ, cricoarytenoid arthritis= smaller ETT
difficult intubation
cspine--> consider c-collar
pre-op imagining
AWAKE fiberoptic intubation! 
avoid hyper extension or flexion

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Anesthesia considerations with rheumatoid arthritis for pre-induction?

Cardiac clearance –> cardiac stable drugs
restrictive lung disease–> PFT ABG post op vent
Steroids- stress dose, ASA & NSAIDS bleeding
drugs induced hepatic and renal dysfunction avoid toradol
positioning is important avoid compression and injury

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what is the hallmark of the Osteoarthritis aka DJD (degenerative joint disease) ?

degeneration of articular cartilage NOT associated with systemic inflammation or manifestations

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Anesthesia considerations for Osteoarthritis?

Positioning! coming in for joint replacements (total knee or hip replacement)
DO NOT require steroids
lumbar involvement = regional anesthesia may not be effective could to paramedian spinal at a 15-20 degree angle
often on NSAIDS= bleeding

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MG is an auto-immune disorder where anti-ACh receptor antibodies damage _________ membrane secondary to ___________ reaction?
and originates in the _____-?

POST synaptic
complement mediated reaction
THYMUS

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Clinical features of MG that concern us?

respiratory weakness and laryngeal and pharyngeal muscles! may stay intubated post-op
dysphagia = high risk aspiration!
symptoms worsen throughout the day schedule these patients first thing in the AM
heart block, afib–> ECG

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Treatment for MG?

cholinesterase inhibitors STOP day of surgery usually on pyridostigmine
immunosuppressants -aseptic tech
corticosteroids-stress dose
thymectomy- for thymoma

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Anesthesia considerations for MG ?

elective surgery pt must be in remission
first case of the day 
stress dose corticosteroids 
hold anti cholinesterase day of surgery
Aspiration risk-RSI
short acting barbs or propofol for induction
limit opioids use resp depression
IA good choice
POST OP VENT LIKELY

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MG and muscle relaxant considerations?

resistance to succ = give larger dose RSI 1.5mg/kg
sensitive to NDMR= lower dose and use PNS
reverse with EDROPHONIUM w/ atropine

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MG has drug interactions with what drugs?

antibotics- aminoglycosides clindamycin aggravates the disease
antiarrhythmics
diuretics

extubation with the patient who has MG?

needs to be responsive
generate neg inspiratory pressure > -20cm
needs post op observation in pacu or icu
resume pyridostigmine regimen
if resp. depress. = IV anti-cholinesterase and perhaps re-intubate
RA good choice for thymectomy

Myasthenic Syndrome aka Lambert Eaton Syndrome is associated with a _________ specifically ________. It’s autoimmune ____ for against voltage gated ________ channels on the ____________ of the neuromuscular junction.

neoplasm -Small cell carcinoma of the lung
IgG
Ca ion
PRE SYNAPTICALLY

Myasthenic syndrome has what type of weakness and when is muscle strength increased?

proximal extremity weakness legs>arms

exercise improves strength (opposite of MG)

Treatment for Myasthenic syndrome includes?

Aminopyridines = block K channels and prolongs AP

*anticholinesterase provide minimal improvement can use to diagnose between MS and MG

Compare and contrast MG and Myasthenic syndrome?

MS- proximal limb, exercise improves strength, muscle pain common
reflexes absent or decreased, M>F, assoc with SCC of lung
sensitive to succ and NDMR= use small doses, poor response to anticholinesterases

MG- extraocular, bulbar, facial muscle weakness, fatigue with exercise, muscle pain uncommon, reflexes normal, F>M, assoc. w/ thymoma, resistant to succ sensitive to NDMR, good response to anticholinesterase

Duchenne Muscular dystrophy genetic abnormality in lack of __________. Characterized by ________ and _________________.

dystophin

painless degeneration and atrophy of skeletal muscle
* also weakens cell membrane = Increase CA into cell

Which drugs induce lupus like syndrome?

hydralazine
procainamide
methlydopa 
PTU
phenytoin

Muscular dystrophy hallmark of the disease? and clinical manifesations?

muscle weakness in proximal extremities cluminess weakness pelvic and shoulder girdle axial skeletal imbalance= kyphoscoliosis= difficult airway GI hypomotility = aspiration risk smooth muscles aka heart decrease contractility

Respiratory concerns with Muscular dystophy?

decreased strength unable to clear secretions impaired cough pneumonia restrictive resp disease

cardiac concerns with Muscular dystrophy?

``` myocard muscle degeneration loss of R wave amplitude on ECG Vent dysrhythmias decrease contractility R vent outflow obstruction & Rsided HF ```

Anesthesia considerations with muscular dystrophy?

cardiac stable drugs- etomidate prone to MH avoid Succ! flush out machine with 02 avoid IA delayed GI emptying RSI- roc also myocard depression with IA normal to prolonged response to NDMR post op pulm complications should be anticipated regional okay?

Marfan's syndrome is an autosomal dominant inheritance pattern of ________________ related to a mutation in __________ gene. Absence of __________ = disrupt scaffolding needed for elastin deposit

connective tissue FBNI fibrillin

Marfans primarily effects _____,_______,_______?

eyes skeletal CV system

Clinical manifestation of Marfans?

long tubular bones arachnodactyly high arched palate pectus excavatum kyphoscolosis - restrictive lung disease difficult airway hyperextensibility - positioning is important! eyes- b/l dislocation or subluxation of lens, myopia, detach retina

Cardiac manifestation of Marfans?

``` cardiac=cause of death Dilation, Dissection, Rupture of Aorta MV prolapse or regurg arrythmias esp BBB CHF Bacterial endocarditis-prophylactic antibiotics ```

Pulmonary and Marfans?

``` kyphoscolsiosis=restrictive low TV etc prone to spontaneous pneumos induce with high opioids lidocaine want to blunt airway responses to avoid HTN and tachycardia esp if they have a AAA pulm HTN Art-alveolar gradient INCREASES ```

Marfan treatment?

Beta blockers to reduce workload on the heart prevent aorta enlarge. can get aortic repair spinal fusion for scoliosis

Marfan anesthetic considerations?

``` assess severity of lung disease- PFTS Airway mgmt: controlled ventilation & adequate oxygenation positioning! cardiac assessment- Beta blockers prophylactic antibiotics= endocarditis avoid extreme movement of mandible with intubation want smooth DVL avoid SNS responses consider TEE assess for penumo ```

Ankylosing spondylitis is characterized by what?

progressive inflammatory disease of spine and adjacent tissues unknown cause -> human leukocyte antigen HLA B27 rheumotoid factor negative= nonrheumatic athropathy ANA negative

Clinical manifestation of ankylosing spondylitis?

hallmark: scaroilliac joint pain dramatic loss of flexibility in lumbar spine towards upper back & neck morning stiffness improved with activity ! fatigue wt loss low grade fever eye inflamm conjunctivitis fused lumbar and cervical spine (def doing awake fiberoptic intubation)

Cardiac and pulmonary manifestations with ankylosing spondylitis?

cardiac- conduction abnormalities pulm: fibrosis, apical cavity lesions, pleural thickening, decreased compliance, decrease VC.... = restrictive lung disease

Treatment for ankloysis spondylitis?

exercise NSAIDS (Indomethacin, sulfasalazine, methotrexate) life long tx spinal fusion in the upright position

anesthesia considerations for ankylosing spondylitis?

``` difficult airway-awake fiberoptic restrictive lung disease cardiac invovlement- maintain SVR avoid sudden changes consider regional controlled ventilation ```

Achondroplasia-drawfism is characterized by what?

congenital disorder of growth plate, impaired cartilage maturation, decreased dendochondral ossifcation (short tubular bones) kyphoscoliosis NORMAL MENTAL capacity, skeletal muscle development, and life expectancy.

Anesthesia considerations for achondroplasia?

likely coming in for sub occipital craniotomy, laminectomy, ventricular peritoneal shunts difficulty airway - upper airway obstruction difficult to expose glottis pituitary associated- small airway peds size ETT OSA or central sleep apnea restrictive lung disease pulm HTN cor pulmonale hydrocephalus thermal regulation abnorm ---HYPERTHERM suscept but not MH no change in response to anesthetics and NMBs