Musculoskeletal Diseases Flashcards
SLE like syndrome may also be drug induced???
Hydralazine
Procainamide
Methyldopa
also Phenytoin (dilantin)
SLE:
These autoantibodies usually affect the ___ of the cell which join with substances to form molecules called ___ - these cause ___ and ___ as they are deposited throughout the body.
*Considered the mainstay of treatment of SLE?
nucleus *immune complexes* inflammation tissue injury *Steroids - Need to consider perioperative steroid coverage
SLE diagnosis confirmed with 3 of 4 typical manifestations? (5)
- antinuclear antibodies
- rash
- thrombocytopenia
- serositis
- nephritis
SLE - Drugs for Chronic Renal Failure:
Need to AVOID these drugs? (7)
Meperidine Thiopental Methohexital Pancuronium d-tubocurarine Metocurine Gallamine
Chronic inflammatory disease characterized by symmetric poly-arthropathy and systemic involvement?
-Peak age of occurrence is ?
Rheumatoid Arthritis
-20-40 years old
Rheumatoid Arthritis:
Believed to be due to an ___ or ___ that leads to an immunological response in a genetically predisposed individual.
-Target is the ___.
antigen or microbe
-synovium
Hallmark is the degeneration of articular cartilage?
Disparity btw the stress applied to articular cartilage and the ability of the cartilage to withstand stress.
- Commonly referred to as?
- Not associated with ___ or ___.
Osteoarthritis
- Degenerative Joint Disease (DJD)
- systemic inflammation or manifestations
DO NOT TYPICALLY REQUIRE STEROIDS?
OSTEOARTHRITIS
Disease of the neuromuscular junction caused by a decrease in the population of the Acetylcholine receptors?
-This process is thought to originate in the ?
Myasthenia Gravis
-Thymus
- Onset may be insidious or abrupt
- Acquired autoimmune disorder of neuromuscular transmission characterized by muscle weakness?
Myasthenia Gravis
Myasthenia Gravis: Anti-acetylcholine receptor antibodies damage the ___ secondary to a ___.
post-synaptic membrane
complement-mediated reaction
Autoimmune disorder of neuromuscular transmission? (aka?)
Develops in association with a neoplasm specifically a ___.
Myasthenic Syndrome
Lambert-Eaton Syndrome
small cell carcinoma of the lung
Myasthenic Syndrome - Auto-immune disorder in which ___ form against the voltage gate ___ ion channels on the ___ side of the NMJ.
If a tumor is present these autoantibodies are directed at the tumor but cross react with ___ in the NMJ.
Immunoglobulin G antibodies (IgG)
calcium
pre-synaptic
calcium channels
Chronic inflammatory multi-system disease characterized by anti-nuclear antibody production?
- Antinuclear antibodies directed at antibodies to:
- DNA
- Histones
- Non-histone proteins bound to RNA
- Nuclear antigens
Systemic Lupus Erythematosus
Increased muscle strength after exercise?
Myasthenic Syndrome
Genetic abnormality due to the lack of production of dystrophin?
- Characterized by a ___ degeneration and ___ of skeletal muscle tissue.
- Dystrophin deficiency weakens the ___ and results in an increase in ___ into the cell.
Duchenne Muscular Dystrophy
- painless
- atrophy
- muscle cell membrane
- calcium
SLE = Choose drugs that are myocardial sparing and not excreted via the kidneys:
- Give propofol doses with incremental dosing sparingly
- ___ if you need a MR (cleared via Hoffman elimination)
- What kind of treatment are they on - they might need to be on a stress dose
- Positioning huge - these patients have LOTS OF PAIN
- Pre-anesthetic want to look at their heart, stress test, listening for friction rubs
- These patients can also have ___ and presenting with hoarse voice - should you use a smaller tube?
- Cisatracurium
- cricoarytenoid arthritis
*Coronary atherosclerosis is the prominent cause of death in ___ - this is from chronic steroid treatment.
Lupus
Affects the upper cervical spine, not the lumbar spine. Can consider regional anesthesia as long as it is in the lumbar spine. Major consideration for patients with ___ is what is going on in their upper cervical spine - will they be a difficult intubation.
- Anesthesia = Consider ___ dose.
- Ask them to avoid ___ and ___ preoperatively.
- Thus these patients will be in pain. Do not give these patients ___ preoperatively - patient at risk for bleeding.
Rheumatoid arthritis
- steroid stress
- ASA and NSAIDs
- toradol
___ - ANESTHETIC CONSIDERATIONS
Biggest concern with RA is the airway. These patients also present with atlanto-axial instability. Very important to not do extension/flexion with these patients. CT and X-rays should be done assessing flexion and extension prior to any surgery.
*Usually first symptom is neck pain radiating to the occiput, however majority of these patients will be asymptomatic.
Rheumatoid Arthritis
Myasthenia Gravis:
- Precipitated by ___, ___, ____
- Initial symptom may present as ____.
- ___ that we give that can aggravate muscle weakness - ___ - at risk for developing respiratory failure
- These patients are at high risk for ___
- At risk for Heart Block look at preoperative EKG
- electrolyte abnormalities, pregnancy, stress
- double vision aka diplopia
- Antibiotics, clindamycin
- aspiration
Myasthenia Gravis Treatment = Typically on ___ (ex-?) daily PO
Do not want patients to take this the day of surgery. Could interact with other meds.
*Too much Cholinesterase - abdominal cramping, diarrhea, excess secretions etc. These patients usually in good control of how much they should take a day.
-Want to do procedure when they patients are healthy - do not do with new onset temp, respiratory infection at risk for complications.
-Perform surgery when patient is in remission - schedule case for first procedure of the day.
Cholinesterase Inhibitors
Pyridostigmine
- –These patients are prone to cardiac depression (avoid ___) and they are prone to MH!?! THUS NO ___!!!
- With induction probably going to be using ___.
- For maintenance possibly use ___ (?), can use ___ and ___, put a big piece of tape over inhaled agents or take them off the machine so no one uses them accidentally
Muscular Dystrophy (inhaled agents) -SUCC -Etomidate -TIVA (propofol) -O2 and N2O
Marfan’s Syndrome:
- ___ inheritance pattern of connective tissue.
- Connective tissue disorder related to a mutation in the ___.
- Absence of ___ disrupts the scaffolding needed for the deposit of ___ in elastin fibers.
- Primarily affects: ???
- Autosomal dominant
- FBN1 gene
- fibrillin
- elastin
- eyes, skeletal, cardiovascular system
- With this patient will usually have restrictive lung disease - want small tidal volumes (4-8 ml/kg).
- With induction concerned about blunting the response - going to use a lot of narcotics on these patients!
- Use ___ - cardiac safe using a lot!
- ___ is huge!!!
- Airway - high arched palate, may need to use a ___ instead due to long palate
Marfan’s Syndrome
- Fentanyl
- Positioning
- miller blade
Progressive inflammatory disease of the spine and adjacent tissues?
- Considered a ___. Cause is not known Human Leukocyte Antigen (HLA-B27).
- ___ and ___ are NEGATIVE.
Ankylosing Spondylitis
- nonrheumatic arthropathy
- Rheumatoid factor and ANA
Going to do AWAKE FIBEROPTIC on these patients!!!
Pre-induction going to do all 3 airway blocks or we can also do 4% nebulized lidocaine (breathe in for 10 minutes - this is the preferred method).
-Avoid sudden changes in ___ because of their cardiac involvement.
-Want to do a ___ and maintain their ___.
-If try to do an induction on these patients it is going to be an airway nightmare!
Ankylosing Spondylitis
- SVR
- controlled ventilation and maintain their SVR
Abnormal bone growth that is responsible for several potential anesthesia related problems?
Not particularly anatomic abnormalities. Use airway appropriate for pediatrics. Anatomy is more similar to that of a child. But their an adult so be cautious of an aspiration risk - going to use a cuffed tube in adult with pituitary dwarfism.
-Oral airway is going to be very important during induction.
-Can have cervical spine instability risk for neck trauma with ___.
Achondroplasia
-overextension
Achondroplasia:
- Thermal regulation abnormalities - ___ susceptible!!!
- No change in responses to ___ and ___.
- Hyperthermia
- Anesthetics and Neuromuscular Blockers
- SLE = Use drugs that are myocardial sparing, not excreted by kidneys:
- Give ___ doses with incremental dosing sparingly
- ___ if you need a MR (cleared via Hoffman elimination)
- What kind of treatment are they on - they might need a ___
- Positioning huge - these patients have LOTS OF PAIN
- Pre-anesthetic want to look at their heart, stress test, listening for ?
- These patients can also have ___ and presenting with hoarse voice
- propofol
- Cisatracurium
- stress dose
- friction rubs
- cricoid arytenoiditis - may need to use a smaller tube
Both of these are treated with ASA and NSAIDs??
Careful with possible bleeding!!
-With MG will have muscle weakness, anesthetic consideration caution with ?
Rheumatoid arthritis (first line tx for pain and inflammation)
Osteoarthritis
-muscle relaxants
Myasthenia Gravis:
Consider aspiration risk - RSI!
With induction use a short acting ___ or ___
-___ use limited
-___ good choice for intubation and maintenance
-Likely will need?
short acting barbiturate or propofol
- opioid
- inhaled agents
- postop ventilation
Myasthenia Gravis:
- Reversal obtained best with ?
- Drug interactions seen with (3)
- Extubation - patient needs to be responsive and generate a negative inspiratory pressure of ___.
- If respiratory depression occurs give ___, possible reintubation with mechanical ventilation
- edrophonium, give with atropine
- antibiotics (aminoglycosides), antiarrhythmics, diuretics
greater than 20 cmH2O
-anticholinesterase IV
All of these disease may result in kyphoscoliosis thus these patients will have restrictive lung disease (require low TV) and pulmonary hypertension (3)
Muscular Dystrophy
Marfan’s
Achondroplasia
- Presence of calcium channel antibodies with?
- Clinical hallmark is muscle weakness pronounced in the proximal extremities?
- Hallmark is sacroiliac joint pain?
- Hallmark is muscle weakness?
- Myasthenic syndrome (increased muscle strength after exercise)
- Muscular dystrophy (usually die in 20s from resp/cardiac issues!)
- Ankylosing Spondylitis (morning stiffness improves with activity)
- Myasthenia Gravis (affects eyes, face - fatigue after activity)
All of these disease may result in kyphoscoliosis thus these patients will have restrictive lung disease (require low TV) and pulmonary hypertension (3)
Muscular Dystrophy
Marfan’s
Achondroplasia
- Presence of calcium channel antibodies with?
- Clinical hallmark is muscle weakness pronounced in the proximal extremities?
- Hallmark is sacroiliac joint pain?
- Hallmark is muscle weakness?
- Myasthenic syndrome (increased muscle strength after exercise)
- Muscular dystrophy (usually die in 20s from resp/cardiac issues!)
- Ankylosing Spondylitis (morning stiffness improves with activity)
- Myasthenia Gravis (affects eyes, face - fatigue after activity)
