Musculoskeletal Flashcards
1
Q
What is scleroderma and who is affected?
A
- inflammation & autoimmunity
- vascular injury
- fibrosis
- females predominantly
2
Q
Scleroderma and the pregnant patient.
A
pregnancy may accelerate symptoms
3
Q
What is CREST syndrome
A
Scleroderma can lead to CREST:
- calcinosis
- reynauds
- espophageal hypomotility
- sclerodactyly
- tanglectasias
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
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
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
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)
8
Q
Scleroderma: ENT effects and anesthesia considerations
A
- dry eyes
- oral/nasal tanglectasias - BLEEDING
- dry mouth
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
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**
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
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
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
14
Q
SLE: Airway manifestations
A
LARYNGEAL INVOLVEMENT IN UP TO 1/3 OF PTS
- -Mucosal irritation
- -cricoarytenoid arthritis
- -recurrent laryngeal nerve palsy
15
Q
SLE: lungs manifestations
A
- “lupus PNA”
- restrictive pattern
- recurrent atelectasis (phrenic nerve neuropathy)
16
Q
SLE: kidney manifestations
A
-glomerulonephritis leading to nephrotic syndrome and RF
17
Q
SLE: heart manifestations
A
-
pericarditis - MOST FREQEUENT CARDIAC MANIFESTIONS
-
assessment:
- chest pain
- friction rub (auscultation)
- ECG changes (EKG)
- pericardial effusion (chest xray)
-
assessment:
- valvular disease
18
Q
SLE: most common symptoms
A
- polyarthritis/dermatitis
- 90% have symmetrical arthritis
- pain out of proportion to degree of synovitis
- 90% have symmetrical arthritis
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
SLE: considerations of drugs for altered renal function
* 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
Rheumatoid Arthritis: Positioning and AW considerations
* 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
RA: drugs to treat pain and inflammation
* ASA
* NSAIDs
* corticosteroids (for acute periods only)
28
RA -- DMARDS: use + agents
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
OA, anesthetic considerations: drugs used in TX
* corticosteroids NOT recommended
* NSAIDs and ASA --potential bleeding issues
30
OA, bone cement implantation syndrome: What is It? Manifestations?
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
List potential stressors that exacerbate MG.
* surgery
* infection
* stress
* pregnancy
32
Myasthenia Gravis: PO pyridostigmine pharmacokinetics
* 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
Why is thymectomy a tx for MG?
MG has an association with thymic hyperplasia and thymoma
34
Myasthenic syndrome: clinical features
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
Myasthenic syndrome: considerations for administration of NMB agents
* 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
What are typical systems affected by Marfan's syndrome and what are the classic manifestations of each?
* **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
Marfan's Syndrome: Pulmonary clinical manifestations
* high incidence of pneumothorax
* spinal/sternal deformities can lead to restrictive lung disease
38
Marfan's Syndrome: CV clinical manifestations
* 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
Surgical need for evoked potential monitoring: What does this mean for the anesthesia you provide?
* limits anesthetic options
* have to avoid MR
* have to avoid high amounts of VA (maybe use like .5 MAC)
40
What kind of cardiac/pulmonary issues would you see in a pt with achondroplasia?
* 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
Why do pts with achondroplasia have difficult IV and central line access?
* short neck
* excess skin and SQ tissue
42
What are some positioning considerations for the pt with achondroplasia?
* foramen magnum stenosis
* fusion of the atlantooccipatal joint with the odontoid
* atlantoaxial instability
* bulging discs
* cervical kyphosis common
\*\*AVOID HYPEREXTENSION DURING INTUBATION\*\*
43
Achondroplasia: How can facial features lead to difficult mask managment?
* large protruding forehead
* short maxilla with long mandible
* flat nose and large tongues
44
Achondroplasia: Besides positioning difficulties, what anatomical features can make intubation difficult in an achondroplastic patient? What can we do to aid our intubation?
* 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
