Musculoskeletal diseases 3 Flashcards
Preoperative findings in the patient with Duchenne muscular dystrophy include: (select 2)
a. mitral stenosis
b. pulmonary fibrosis
c. increased creatine kinase
d. deep Q waves in the limb leads
c. increased creatine kinase
d. deep Q waves in the limb leads
The most common skeletal muscle myopathy is
Duchenne Muscular Dystrophy (DMD)
Duchenne muscular dystrophy results from the absence of
dystrophin protein
Patients with DMD are at risk for
an MH-like syndrome characterized by hyperkalemia & rhabdomyolysis (not true MH though)
Best practices for drugs to give and avoid with DMD include
do: TIVA
avoid: succinylcholine & volatile anesthetics
With DMD, there’s a progressive deterioration of
skeletal muscle strength in the first decade of life, culminating in profound weakness
Describe associated issues with DMD.
kyphoscoliosis (restrictive lung disease)
congestive heart failure
risk of aspiration
Describe the pathophysiology of Duchenne muscular dystrophy.
the absence of dystrophin destabilizes the sarcolemma during muscle contraction
the breakdown of the sarcolemma allows creatine kinase and myoglobin to enter the systemic circulation
calcium freely enters the cell, which activates proteases that destroy the contractile elements and cause inflammation, fibrosis, and cell death
Other types of muscular dystrophy include
Becker
Emery-Dreifuss
facioscapulohumeral
limb-girdle muscular dystrophy
Describe the respiratory considerations for patients with DMD.
respiratory muscle weakness
kyphoscoliosis (restrictive lung disease)–> decreased pulmonary reserve–> increased secretions and risk of pneumonia
Describe the cardiac considerations for patients with DMD.
degeneration of cardiac muscle–> reduced contractility, papillary muscle dysfunction, mitral regurgitation, cardiomyopathy, and CHF
s/s of Cardiomyopathy include resting tachycardia, JVD, S3/S4 gallop, and displacement of the point of maximal impulse
Patients with DMD should receive _____ prior to surgery
a cardiac workup
Describe the GI considerations for patients with DMD.
Impaired airway reflexes and GI hypomotility–> increased risk of pulmonary aspiration
Describe the EKG changes for patients with DMD.
impaired cardiac conduction–> sinus tachycardia and short PR interval
scarring of the posterobasal aspect (back/bottom) of the left ventricle manifests as increased R wave amplitude in lead I and deep Q waves in the limb leads
The Cobb angle describes
the magnitude of spinal curvature in a patient with scoliosis
Describe scoliosis.
A lateral and rotational curvature of the spine and ribcage
Describe kyphoscoliosis
a posterior curvature of the spinal column that produces a restrictive ventilatory defect
A Cobb angle > _________ is an indication for surgery
40-50 degrees
Cervicalscoliosis can cause
difficult intubation
A vital capacity of <40% predicted with scoliosis correlates with
requirement for post-op ventilation
Risks for scoliosis surgery include
prepare for significant blood loss
venous air embolism is a risk
monitor end-organ perfusion with serial ABG (risk of metabolic acidosis) and urine output
Thoracic correction of scoliosis higher than _____ may require one-lung ventilation
T8
Describe the etiology of scoliosis.
idiopathic (incidence= 80%)
congenital
myopathic (muscular dystrophy & amyotonia congenita)
neuropathic (cerebral palsy, syringomyelia, Friedreich’s ataxia)
traumatic
Pulmonary symptoms are present at a Cobb angle of
70 degrees
At a Cobb Angle of 100 degrees,
gas exchange is significantly impaired
higher risk of postop pulmonary complications
Cardiac complications, such as __________, are the result of ______________
RV hypertrophy; increased pulmonary vascular resistance
An EKG may reveal ____________ & _____________ for patients with scoliosis
RV strain & right atrial enlargement
Co-existing cardiac conditions for patients with scoliosis include
mitral valve prolapse (most common)
mitral regurgitation
coarctation of the aorta
Deliberate hypotension to maintain MAP 60 mmHg for spinal rod insertion surgery carries the risk of
cerebral hypoperfusion and ischemic optic neuropathy
If a patient can move their hands but not their feed on a wake up test, then
the surgeon should reduce distraction on the spinal rods
Risks of the wakeup test include
pain
awareness
tracheal extubation
removal of lines
air embolism
damage to surgical instrumentation
What three places does rheumatoid arthritis impact the airway in?
temporomandibular joint
cricoarytenoid joint
cervical spine
The most common airway complication of rheumatoid arthritis is
atlantoaxial subluxation and separation of the atlanto-odontoid articulation
** risk for quadriparesis or paralysis
RA decreases _____________ and the size of __________
mouth opening and the size of the glottic opening
In terms of the airway setup for patients with RA, it is important to use
a smaller ETT to minimize laryngeal trauma d/t decreased size of glottic opening
Patients with RA are at high risk of ___________post-extubation
airway obstruction
Patients with arthritis to the cricoarytenoid joints will present with
hoarseness, stridor, dyspnea, and may result in airway obstruction
Anesthetic considerations for the patient with rheumatoid arthritis include (select 3):
a. aortic regurgitation
b. obstructive ventilatory pattern
c. hypercoagulability
d. hypoglycemia
e. anemia
f. pulmonary effusion
e. anemia
f. pulmonary effusion
a. aortic regurgitation
Rheumatoid arthritis is an
autoimmune disease that targets the synovial joints
The hallmark symptoms of RA include
morning stiffness that improves with activity
painful, swollen, and warm joints
weakness, fatigue, and anorexia
RA affects ________ where as OA typically affects ________
interphalangeal and metacarpophalangeal joints in the hands and feet; weight bearing joints
Medical management of RA includes
reducing inflammation with antirheumatics, glucocorticoids, and NSAIDs
Concerns with antirheumatic drugs include
they suppress the immune system and increase the risk of infection and cancer
Examples of antirheumatics include
methotrexate, cyclosporine, and etanercept
Systemic involvement of rheumatoid arthritis includes
vasculitis to the small and medium arteries
Hematologic complications of RA include
anemia
platelet dysfunction secondary to NSAIDs
Eye complications of RA include
Sjogren’s syndrome–> risk of corneal abrasian
Nervous system complications of RA include
peripheral neuropathy due to nerve entrapment
Renal system complications of RA include
renal insufficiency due to vasculitis and NSAID use
Endocrine system complications of RA include
adrenal insufficiency and infections due to chronic steroid therapy
Pulmonary complications of RA include
restrictive ventilatory pattern (limits chest wall expansion)
pleural effusion
Cardiac complications of RA include
aortic regurgitation
valvular fibrosis
pericardial effusion or tamponade
restrictive pericarditis
coronary artery arteritis
Lab testing for RA includes
rheumatoid factor which is an anti-immunoglobulin antibody that is increased in 90% of patients with RA
increased C-reactive protein
increased erythrocyte sedimentation rate
