Musculoskeletal (2) Flashcards
Most common chronic inflammatory arthritis, 2-3x higher in women than men
Rheumatoid arthritis
What is an IG antibody that is present in 90% of RA patients?
Rheumatoid factor
Where do rheumatoid nodules appear?
Pressure points; under elbows
When is fusiform swelling typical?
When there is involvement of the proximal interphalangeal joints?
What are some characteristics of Rheumatoid arthritis?
- painful synovial inflammation, swelling, and increased fluid
- morning stiffness
- symmetrical distribution of several joints
- fusiform swelling
- synovitis of temporomandibular joint
what are symptoms of acute cricoarytenoid arthritis?
hoarseness, dyspnea, and stridor with tenderness over the larynx; swelling and redness of arytenoids
What are symptoms of chronic cricoarytenoid arthritis?
Asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction
What are s/s of rheumatoid arthritis?
- atlantoaxial subluxation
- cricoarytenoid arthritis
- osteoporosis
- NM: weakened skeletal muscles and peripheral neuropathies
What are CV concerns for rheumatoid arthritis?
Pericarditis, accelerated coronary atherosclerosis, cardiac valve fibrosis, conduction defects
What are pulmonary concerns for rheumatoid arthritis?
Restrictive lung changes, pleural effusion, rheumatoid nodules (resembles TB or CA on CXR)
What is another name for scleroderma?
Systemic Sclerosis
What is Scleroderma?
- Inflammation and autoimmunity
- Vascular injury with vascular obliteration
- Tissue fibrosis and organ sclerosis
What is CREST syndrome in association with Scleroderma?
Calcinosis: Ca++ deposits in skin
Raynauds Phenomenon: Spasms of blood vessels in response to cold or stress
Esophageal Dysfunction: GERD, Decrease motility
Sclerodactyly: Thickening and tightening of skin on fingers and hands
Telangiectasis: Dilation of capillaries causing red marks on skin surface
What diagnostic test can be used to help ID pulmonary HTN?
CXR: Enlarged RV
If a patient has pulmonary HTN fro Scleroderma what med would you want to use for induction?
Etomidate
How does the skin look in pts with scleroderma?
Taut
How does Scleroderma affect musculoskeletal system?
Limited mobility/ contractures and skeletal muscle myopathy
How is the nervous system effected by Scleroderma?
Nerve compression
How is CV system impacted by scleroderma?
Systemic and pulmonary HTN, dysrhythmias, vasospasm in small arteries of fingers, CHF
Increased risk for pericarditis and pericardial effusion
How does scleroderma affect GI?
*Xerostomia (dry mouth)
*Poor dentation
*Fibrosis of GI tract
* Reflux
How does scleroderma affect renal system?
- Decreased RBF and systemic HTN
What are the treatment options for Scleroderma?
Alleviate Symptoms
- ACE-inhibitors
- PPI
- CCB
- Want to have recent echo
What is the drug of choice for patients on ace-inhibs who go hypotensive?
Vasopressin
Airway considerations for someone with Scleroderma:
- Mandibular motion
- Small mouth opening
- Oral bleeding
What can you do if patient with scleroderma is bleeding in their mouth post intubation (keeps oozing)?
- Local phenylephrine
- IV TXA
- Vitamin K
- Ca++
Where would be the best site if you have to place an art line in a patient that has scleroderma?
Larger vessel
want to prevent vaso-occlusive crisis
What are some consideration when a patient with scleroderma is intubated?
- Decreased pulm compliance and reserve
- Avoid increasing PVR
_____ is 3x more common in patients with Sclerodema.
VTE
- Prophylaxis with SQ hep 5000u
What is a concern with the eye for patient with scleroderma?
Corneal abrasions (from dry eyes)
What is another term for pseudohypertrophy muscular dystrophy?
Duchenne Muscular Dystrophy
Pseudohypertrophy Muscular Dystrophy is a ______ linked _______ trait
X-linked recessive
What gene has the mutation for duchenne MD?
- Mutation in the dystrophin gene (large protein that stabilizes muscle membrane)
What does the term Pseudohypertrophic mean?
Muscle appear enlarged but its actually being replaced by fatty infiltrations
Duchenne MD most common in girls or boys? What are the initial symptoms?
Boys
Waddling gait, frequent falls, difficulty climbing stairs
Usually WC bound by 8-10 y/o
Usually don’t live past 20-25y/o
What is the primary complication that causes premature death in duchenne MD?
CHF and/or PNA (pulmonary complications)
What are CNS S/S for Pseudohypertrophy MD?
Intellectual disability
What are musculoskeletal issues that occur with Pseudohypertrophy MD progression?
- Kyphoscoliosis
- Skeletal muscle atrophy
- Increase serum CK (20-100x norm–renal fx)
What are CV issues in patients with pseudohypertophy MD?
- Sinus Tachycardia
- Cardiomyopathy
- Short PR, tall R waves (V1), deep Q waves
Preop EKG/echo
What are pulmonary complications in patient with duchenne MD?
- Weak respiratory muscles
- Weak cough
- Increased secretions
- Loss of pulm reserve
probably want to avoid NMB with these guys
If you do have to give NMB to patient with duchenne MD, what would you anticipate?
*Potential they wont be able to get off vent
* Full reversal with Sugammadex
GI consideration for pt with duchenne MD:
Delayed gastric emptying (Aspiration risk)
Why is Succinylcholine avoided in patients with Duchenne MD?
Increases risk of rhabdo, hyperkalemia, MH, and cardiac arrest
What type of anesthesia would be a better option for Duchenne MD patients?
Regional Anesthesia: avoids risks of GA, provides post op analgesia, and facilitates chest physiotherapy
would maybe need Ketamine or Precedex to facilitate Regional
What causes Myasthenia Gravis?
- Chronic autoimmune disorder
- Decreased functional post-synaptic ACh receptors
- ACh receptor-binding antibodies and thymus abnormalities
What are classic S/S of Myasthenia Gravis?
- Muscle weakness with rapid exhaustion of voluntary muscles (exhaustion with basic activities)
- Partial recovery with rest
- Ptosis, Diplopia, Dysphagia
- Dysarthria
- Isolated resp failure
- arm, leg, trunk weakness
- Myocarditis
How is Myasthenia Gravis classified?
Type 1-4
- Type 1: Limited involvement of the extraocular muscles (unlikely disease progression)
- Type 2: slow progression
- Type 3: acute onset (< muscle strength in 6 months)
- Type 4: Severe skeletal muscle weakness
What autoimmune diseases are associated with Myasthenia Gravis?
- RA
- SLE
- Pernicious anemia
- Hyperthyroidism
What is a common reason for myasthenia crisis? What are the symptoms?
- Drug resistance or Insufficient drug therapy
- Severe muscle weakness and respiratory failure
What is a cholinergic crisis? What are S/S?
- Excessive Anticholinergic treatment
- Muscarinic side effects: profound muscle weakness, salivation, miosis, bradycardia, diarrhea, abdominal pain (SLUDGE-M)
What test is used to diagnose MG?
Tensilon test: Edrophonium 1-2mg IVP
- Improved MG
- Worsens cholinergic crisis
What is first line therapy for Myasthenia Gravis?
Anticholinesterases: increase ACh at NMJ
* Pyridostigmine > Neostigmine
* Could cause pt to have tolerance to NMB (maybe avoid NMB)
What surgical treatment can be considered with MG type 2 or 3?
Thymectomy:
* Induces remission or allows reduction of immunosuppressive drugs
* Recudes ACh antibody levels
* Full benefit delayed a few months postop
When is immunosuppression indicated for patient with MG?
When skeletal muscle weakness is not controlled by anticholinergics
Immunosuppression: Steroids, azathioprine, cyclosporin, mycophenolate
What are options for immunotherapy for patients with MG?
- Plasmapheresis: removes antibodies
- Immunoglobulin injections: temporary effect if on verge of crisis
What are anesthesia management considerations for patients with MG?
- Aspiration risk
- Weakened pulmonary effort
- Marked sensitivity to non-depolarizing NMB (or no response to NMB at all)
- Resistant to Succyinylcholine
*Intubate without NMB or use intermediate-acting NMB
What med can be used for induction instead of succinylcholine in patients with MG?
Remifentanil
or can intubate using volatile agent
What is the most common joint disease and leading chronic disease of the elderly population?
Osteoarthritis
How is osteoarthritis pain characterized?
Pain present with motion, relieved with rest
*morning stiffness disappears with movement
What is the degenerative process that affects articular cartilage with minimal inflammatory reaction in the joints?
Osteoarthritis
How does osteoarthritis cause joint trauma?
- Biomechanical stresses
- Joint injury
- Abnormal joint loading
- Neuropathy
- Ligament injury
- Muscle atrophy
- Obesity** (Often not surgical candidate until lose weight)
Which areas are most commonly affected by osteoarthritis?
Weight-bearing and distal interphalangeal joints
- Knees and hips most common
What are Heberden nodes and what are they associated with?
Bony growths that develop on the distal interphalangeal joints
Associated with Osteoarthritis
Which parts of the spine are commonly affected by osteoarthritis?
Middle to lower cervical and lumbar spine
*If c-spine usually C6-C7; more commonly lumbar
What is primary treatment for osteoarthritis?
- PT/exercise
- Maintaining muscle function
- Pain relief
- Joint replacement therapy
NO STEROIDS– causes joints to fail faster
What are we concerned about from anesthesia standpoint for patients with OA?
- Airway: worry about neck extension ability
- Limited ROM of extremities
What are hematologic concerns for rheumatoid arthritis?
Anemia, neutropenia, elevated platelets - get a CBC preop
Other s/s of RA that resemble Sjogren syndrome:
Keratoconjunctivitis sicca (dry eyes) and xerostomia
Treatment of RA:
NSAIDs, corticosteroids, DMARDs, tumor necrosis factor inhibitors and interleukin inhibitors, surgery
How do NSAIDs help with RA?
Decrease joint swelling, relieve stiffness, provide anesthesia - COX 1 and COX 2 inhibitors
How do corticosteroids help with RA?
decrease joint swelling, pain, and morning stiffness
- bridge therapy while DMARDs are starting to work
How do DMARDs help with RA?
Halt or slow disease progression - methotrexate
How does surgery help with RA?
Intractable pain, impairment of joint function, joint stabilization; total replacement
How does TNF-alpha inhibitors and IL-1 inhibitors compare to DMARDs?
TNF-alpha inhibitors act more rapidly than other DMARDs;
IL-1 inhibitors have a slower onset and are less effective than TNF inhibitors
Anesthesia considerations for a patient with RA:
- Airway: Atlantoaxial subluxation, TMJ limitation, cricoarytenoid joints
- Severe rheumatoid lung disease
- Protect eyes
- Stress dose
Typical manifestations of Systemic Lupus Erythematosus:
- Antinuclear antibodies
- Characteristic malar rash
- Thrombocytopenia
- Serositis
- Nephritis
SLE manifestations are a result of:
- Tissue damage from vasculopathy mediated by immune complexes
- Direct result of antibodies to cell surface molecules or serum components
What characterizes SLE?
- Multisystem chronic inflammatory
- Antinuclear antibody production
- antibodies in 95% of patients
What population is SLE common in?
Young women and African Americans; ages 15 to 40
CNS S/S of Lupus:
cognitive dysfunction, physiological changes - related to vasculitis and fluid/electrolyte imbalances, fever, HTN, uremia, infection and drug-induced effects
CV s/s of Lupus:
Pericarditis (most common), coronary atherosclerosis, Raynaud’s
Pulmonary s/s of Lupus:
Lupus pneumonia (pulmonary infiltrates, pleural effusion, dry cough, dyspnea, arterial hypoxemia), restrictive lung disease, vanishing lung syndrome (rare, decreased lung volumes, diaphragm elevated)
Renal s/s of Lupus:
glomerulonephritis w/ proteinuria, hematuria, decreased GFR (oliguric renal failure)
GI/liver s/s of lupus:
ABD pain, pancreatitis, elevated liver enzymes
Hematology s/s of Lupus:
Thromboembolism, thrombocytopenia, hemolytic anemia
Other s/s of Lupus:
Skeletal muscle weakness, butterfly-shaped malar rash, discoid lesions, alopecia
Treatment for SLE:
- NSAIDs or ASA
- Anti-malarial: hydroxychloroquine and quinacrine
- Corticosteroids
- Immunosuppressants: methotrexate, azathioprine
Anesthesia management for SLE:
- Based on manifestation and organ dyfunction
- Airway: recurrent laryngeal nerve palsy, cricoaryteniod arthritis, upper airway obstruction
- Stress dose of corticosteroids
Malignant hyperthermia is considered a ____ syndrome
Hypermetabolic
What is the genetic mutation in malignant hyperthermia?
- Ryanodine receptor - RYR1 gene
- Dihydropyridine receptor
What is the mortality rate for malignant hyperthermia?
50%
What produces the heat in malignant hyperthermia?
The increased activity of pumps and exchangers trying to correct the increase in sarcoplasmic Ca++ associated with triggered MH increases the need for ATP, which produces heat
What leads to rhabdomyolysis in malignant hyperthermia?
Sustained high levels of sarcoplasmic Ca++ that rapidly drives skeletal muscle into a hypermetabolic state that may proceed to severe rhabdomyolysis
What causes the rigidity in malignant hyperthermia?
Result of the inability of the Ca++ pumps and transporters to reduce the unbound sarcoplasmic Ca++ below the contractile threshold
Triggers for malignant hyperthermia:
Volatile anesthetics and succinylcholine (anectine)
EARLY s/s of MH:
- hypercarbia
- tachypnea
- sinus tachycardia
- masseter muscle spasm
- generalized muscular rigidity
- peaked T waves
- metabolic and respiratory acidosis
LATE s/s of MH:
- hyperthermia
- cola-colored urine/rhabdo
- Elevated CPK
- Cardiac dysrhythmia (VT/VF)
- Acute renal failure
- CV collapse
- DIC
Treatment for MH:
- D/C all triggering gas/drugs
- hyperventilate with 100% at 10 L/min
- change breathing circuit and soda lime
- Dantrolene
- Treat arrhythmias
- Monitor urine output
How does Dantrolene work? What is the dosage?
It reduces the concentration of sarcoplasmic Ca++ to below contractile threshold - inhibits release
- 20 mg + 3 G mannitol
- initial dose 2.5 mg/kg
- max upper limit 10 mg/kg
Post-op care for MH:
- transfer to ICU for 24-48 hours
- report to MH registry
- MH testing for pt and family members - muscle biopsy contracture testing; halothane plus caffeine contracture test
CREST syndrome is commonly associated with what disease?
Scleroderma
Tensilon test with edrophonium improves with?
Myasthenia Gravis
RA results in increase pain at what time of day?
Morning
Airway concerns in RA include:
TMJ movement limitation
Atlantoaxial subluxation
Which of the following is not common manifestation of SLE?
Asymmetric arthritis
Horner’s syndrome occurs as a result of which blockade?
Stellate Ganglion (over flow from inter-scalene)
Newer treatment for MH that is less volume than Dantrolene:
Ryanodex
