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NURA 620 Anesthesia and Coexisting Conditions > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What is scleroderma and who is affected?

A
  • inflammation & autoimmunity
  • vascular injury
  • fibrosis
  • females predominantly
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2
Q

Scleroderma and the pregnant patient.

A

pregnancy may accelerate symptoms

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3
Q

What is CREST syndrome

A

Scleroderma can lead to CREST:

  • calcinosis
  • reynauds
  • espophageal hypomotility
  • sclerodactyly
  • tanglectasias
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4
Q

Scleroderma: skin effects and anesthesia considerations

A
  • limited mobility - POTENTIAL SMALL MOUTH OPENING, DIFFICULT AW - FIBEROPTIC?
  • flexion contractures - POSITIONING AND COMFORT PRIOR TO INDUCTION
  • thickened taut skin - IV/A LINES DIFFICULT
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5
Q

Scleroderma: musculoskeletal effects and anesthesia considerations

A
  • myopathy
  • proximal skeletal weakness
  • flexion contractures - POSITIONING AND COMFORT PRIOR TO INDUCTION TO AVOID PAINFUL POSITIONS WHILE UNDER ANESTHESIA
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6
Q

Scleroderma: CNS effects and anesthesia considerations

A
  • thickened connective tissue around nerve sheath leading to neuropathy - DOCUMENT BASELINE, REGIONAL QUESTIONABLE
  • high incidence of trigeminal neuralgia - CURRENT REGIMEN FOR PAIN CONTROL IF PRESENT
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7
Q

Scleroderma: CV effects and anesthesia considerations

A

myocardial tissue replaced with fibrotic tissue - BASELINE ECG/CV WORK UP IF NEEDED

conduction abnormalities - BASELINE ECG/CV WORKUP IF NEEDED

major vascular changes (contracted intravascular volume per Miller) – (HYPOTENSION RISK WITH VASODILATING AGENTS)

remodeling – high incidence pulmonary HTN

vasospasms - Raynauds (CONSIDER WHEN DECIDING UPON ART LINE)

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8
Q

Scleroderma: ENT effects and anesthesia considerations

A
  • dry eyes
  • oral/nasal tanglectasias - BLEEDING
  • dry mouth
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9
Q

Scleroderma: pulmonary effects and anesthesia considerations

A
  • fibrosis - IMPAIRED DIFFUSION CAPACITY - HIGHER FIO2?
  • restrictive pattern - HIGHER PEAK INSPIRATORY PRESSURES, VENTILATE WITH SMALLER TV
  • decreased compliance
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10
Q

Scleroderma: GI effects and anesthesia considerations

A
  • dysphagia
  • hypomotility of lower esophagus & small intestine - CONSIDER RSI; PROPHYLACTIC NON PARTICULATE, PROKINETIC, H2 BLOCKER
  • LES tone decreases - GERD - CONSIDER RSI; PROPHYLACTIC NON PARTICULATE, PROKINETIC, H2 BLOCKER
  • malabsorption

**wouldn’t for sure do an RSI, remember they may be a difficult AW and we may not want to paralyze them so may also consider awake fiberoptic**

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11
Q

Scleroderma: Renal effects and anesthesia considerations

A
  • renal hypertension (ACE inhibitors are effective) -CONSIDER DEGREE OF RENAL DYSFUNCTION AND ANESTHESIA DRUGS THAT UNDERGO RENAL ELIMINATION OR ARE NEPHROTOXIC
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12
Q

Scleroderma: AW considerations

A
  • limited mobility - POTENTIAL SMALL MOUTH OPENING, DIFFICULT AW - FIBEROPTIC?
  • telangiectasias - avoid nasal/oral AW
  • flexion contractures - POSITIONING AND COMFORT PRIOR TO INDUCTION TO AVOID PAINFUL POSITIONS WHILE UNDER ANESTHESIA
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13
Q

SLE: manifestations

A

INFLAMMATION AND VACULITIS

  • vessel wall thickening, weakening, narrowing, and scarring: CAD, Stroke risk, etc.
  • HTN
  • +/- pulmonary HTN - AVOID HYPOXEMIA, HYPERCAPNEA - R HEART STRAIN - ACUTE RV FAILURE
  • Thromboemoblism
  • hypercoagulable state
  • hemolytic anemia
  • frequent fevers

SKIN AND MEMBRANES

  • butterfly rash with nasal erythema (50%)
  • oral and pharyngeal ulcers

JOINT/MUSCLE

  • symmetrical arthritis (90%)
  • cricoarytenoid arthritis
  • AVN (avascular necrosis)
  • myopathy
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14
Q

SLE: Airway manifestations

A

LARYNGEAL INVOLVEMENT IN UP TO 1/3 OF PTS

  • -Mucosal irritation
  • -cricoarytenoid arthritis
  • -recurrent laryngeal nerve palsy
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15
Q

SLE: lungs manifestations

A
  • “lupus PNA”
  • restrictive pattern
  • recurrent atelectasis (phrenic nerve neuropathy)
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16
Q

SLE: kidney manifestations

A

-glomerulonephritis leading to nephrotic syndrome and RF

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17
Q

SLE: heart manifestations

A
  • pericarditis - MOST FREQEUENT CARDIAC MANIFESTIONS
    • assessment:
      • chest pain
      • friction rub (auscultation)
      • ECG changes (EKG)
      • pericardial effusion (chest xray)
  • valvular disease
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18
Q

SLE: most common symptoms

A
  • polyarthritis/dermatitis
    • 90% have symmetrical arthritis
      • pain out of proportion to degree of synovitis
19
Q

SLE: CNS manifestations

A

1/3 of patients have cognitive symptoms

20
Q

SLE: liver manifestions

A
  • biliary cirrhosis
  • autoimmune hepatitis
21
Q

Stress dose steroids in the peri operative setting: considerations (on slide)

A
  • if pt already on steroids, continue at usual dose if possible
  • data supporting administration of stress doses limited, decision to administer stress dose depends on procedure
  • small procedures (i.e. dental work, skin biopsies), no stress dose necessary
22
Q

Stress dose steroids in the peri operative setting: dosing recommendations

A
  • moderate procedures: 25 mg hydrocortisone q8h, then taper over 1 to 2 days
  • major surgery: give 50 mg hydrocortisone q8h, then taper over 2 to 3 days
23
Q

Stress dose steroids in the peri operative setting: OG pearls

A
  • If someone has been on LONG TERM STEROIDS, and they HAVEN’T taken their daily dose - GIVE STRESS DOSE
  • If they are undergoing a minor procedure and HAVE taken their dose, and they experience any hypotension – steroids are the first thought
  • If they are undergoing a MAJOR procedure – GIVES STRESS DOSE
24
Q

SLE: neuraxial and regional nerve blocks

A
  • DOCUMENT PREEXISTING PERIPHERAL NEUOPATHIES
  • be aware of current anticoagulants or known coagulopathy
25
Q

SLE: considerations of drugs for altered renal function

A
  • most commonly used drugs in anesthesia are at least partly dependent on renal excretion for elimination
    • dose and frequency modification may be needed to prevent accumulation of the drug OR active metabolites
26
Q

Rheumatoid Arthritis: Positioning and AW considerations

A
  • TMJ may be affected - MOUTH OPENING
  • cervical spine may be affected (atlantoaxial instability and cord compression)
    • CONSIDER AWAKE FIBEROPTIC OR VIDEO LARYNGOSCOPE TO AVOID NECK MANIPULATION
    • DO NOT HYPEREXTEND
    • HAVE THE PATIENT POSITION THEIR OWN NECK
27
Q

RA: drugs to treat pain and inflammation

A
  • ASA
  • NSAIDs
  • corticosteroids (for acute periods only)
28
Q

RA – DMARDS: use + agents

A

alter the immune response, slow disease progression

  • methotrexate
  • azathioprine
  • sulfasalazine (anti inflammatory, mild immunosuppressant)
  • antimalarial drugs
  • minocyclin
  • TNF inhibitors/monoclonal antibodies (de - myelinating syndromes, infection??)
29
Q

OA, anesthetic considerations: drugs used in TX

A
  • corticosteroids NOT recommended
  • NSAIDs and ASA –potential bleeding issues
30
Q

OA, bone cement implantation syndrome: What is It? Manifestations?

A

fat and marrow embolisms

  • -hypoxia (increased pulmonary shunt)
  • -hypotension
  • -dysrhythmias (heart block and sinus arrest)
  • -pulmonary HTN
  • -decreased CO

**GOAL TO PROMOTE FORWARD FLOW**

31
Q

List potential stressors that exacerbate MG.

A
  • surgery
  • infection
  • stress
  • pregnancy
32
Q

Myasthenia Gravis: PO pyridostigmine pharmacokinetics

A
  • onset: 30 min
  • peak: 2 hours
  • DOA: 3-6 hours
  • **important to note, because once this dose wears off their symptoms will be right back to baseline**
  • higher doses paradoxically enhance muscle weakness -“cholinergic crisis”
33
Q

Why is thymectomy a tx for MG?

A

MG has an association with thymic hyperplasia and thymoma

34
Q

Myasthenic syndrome: clinical features

A

presents with proximal muscle weakness

  • -typically begins with LE, spreads to upper limbs, bulbar, resp muscles
  • -change in gait, ability to stand, climb stairs
  • -**exercise improves strength** (increasing quanta of Ach, where as exercise decreases strength with MG)

AUTONOMIC DYSFUNCTION VERY COMMON!

  • -hemodynamic variability
  • -dry mouth
  • -urinary hesitancy
35
Q

Myasthenic syndrome: considerations for administration of NMB agents

A
  • very sensitive to both depolarizing and non depolarizing NMB
  • VA alone often sufficient to provide muscle relaxation for both intubation and most surgical procedures
  • NMBAs should only be given in small increments and with careful neuromuscular monitoring
36
Q

What are typical systems affected by Marfan’s syndrome and what are the classic manifestations of each?

A
  • CV - AORTIC ANEURYSM, AORTIC DISSECTION (most life threatening manifestations –inc risk in pregnancy!!)
    • others include valve prolapse/dysfunction/regurgitation
      • mitral and aortic valve
    • arryhthmias-BBB
    • aortic and AV valves prone to calcification
  • skeletal - long bone overgrowth
  • ocular - dislocation of the ocular lens, retinal detachment
37
Q

Marfan’s Syndrome: Pulmonary clinical manifestations

A
  • high incidence of pneumothorax
  • spinal/sternal deformities can lead to restrictive lung disease
38
Q

Marfan’s Syndrome: CV clinical manifestations

A
  • AORTIC ANEURYSM, AORTIC DISSECTION (most life threatening manifestations –inc risk in pregnancy!!)
  • valve prolapse/dysfunction/regurgitation
    • mitral valve
    • aortic valve
      • incompetence often related to dilation of ascending aorta
  • arrhythmia - BBB
  • aortic and AV valves prone to calcification
39
Q

Surgical need for evoked potential monitoring: What does this mean for the anesthesia you provide?

A
  • limits anesthetic options
    • have to avoid MR
    • have to avoid high amounts of VA (maybe use like .5 MAC)
40
Q

What kind of cardiac/pulmonary issues would you see in a pt with achondroplasia?

A
  • Central sleep apnea (related to brainstem compression by foramen magnum and upper airway obstruction)
  • PHTN leading to cor pulmonale
    • most common CV disturbance that develops in these patients
    • restrictive ventialtory defects may occur and lead to pulm HTN
41
Q

Why do pts with achondroplasia have difficult IV and central line access?

A
  • short neck
  • excess skin and SQ tissue
42
Q

What are some positioning considerations for the pt with achondroplasia?

A
  • foramen magnum stenosis
  • fusion of the atlantooccipatal joint with the odontoid
  • atlantoaxial instability
  • bulging discs
  • cervical kyphosis common

**AVOID HYPEREXTENSION DURING INTUBATION**

43
Q

Achondroplasia: How can facial features lead to difficult mask managment?

A
  • large protruding forehead
  • short maxilla with long mandible
  • flat nose and large tongues
44
Q

Achondroplasia: Besides positioning difficulties, what anatomical features can make intubation difficult in an achondroplastic patient? What can we do to aid our intubation?

A
  • larynx may be small
  • difficult to expose glottis
  • range of tube sizes and difficult airway cart available
  • weight rather than age is best guide for predicting proper size

NURA 620 Anesthesia and Coexisting Conditions (7 decks)

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