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Musculoskeletal Diseases Flashcards

1
Q

Ankylosing Spondylitis (AS)

A
  • Chronic, progressive inflammatory disease involving joints of spine and adjacent soft tissues
  • Associated with Human Leukocyte Antigen (HLA) B27 in most cases
  • Male to female ratio 4:1
  • Important anesthesia implications both articular and non-articular
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2
Q

SLE Manifestations: Heart

A
  • Pericarditis (auscultate friction rub)
  • Valvular disease
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3
Q

Achondroplasia Anesthesia Considerations:

Cardiac and Pulmonary involvement

A
  • Restrictive ventilatory defects may occur and lead to pulm HTN
  • Pulm HTN leading to cor pulmonale is most common CV disturbance that develops
  • Central sleep apnea (related to brainstem compression by foramen magnum), and upper airway obstruction
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4
Q

Scleroderma multi-system effects: Skin

A
  • Thickened taut skin
  • Limited mobility
  • Flexion contractures
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5
Q

Myasthenia Gravis Anesthesia Considerations: Emergence

A
  • At great risk for postop respiratory failure
  • Advise pt may awaken w/ ETT in place
  • Careful eval of ventilatory function prior to extubation
  • Close obs in recovery
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6
Q

Systemic Lupus Erythematosus (SLE): patho/onset/incidence

A
  • Multisystem inflammatory dz characterized by immune-mediated tissue damage
  • Predominantly occurs in females (1:1000)
  • Presence of HTN & nephritis = poor prognosis
  • Onset may be drug induced (milder form, lupus like syndrome):
    • Hydralazine, procainamide, isoniazid, methyldopa
    • Slow acetylators at ↑ risk
  • Physiologic stress can exacerbate disease
    • Surgery; Infection; Pregnancy
      • Poor fetal outcomes (especially if HTN & nephritis)
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7
Q

Mild SLE Treatment

A
  • NSAIDs for joint symptoms and pleurisy
  • Low dose corticosteroids such as prednisone
  • Anti-malarial drugs (hydroxychloroquine/quinacrine) and low-dose corticosteroids for thrombocytopenia, hemolytic anemia, skin, arthritis symptoms
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8
Q

Scleroderma multi-system effects: CV

A
  • Myocardial tissue replaced w/ fibrotic tissue→ conduction abnormalities
  • Major vascular changes
  • High incidence pulm HTN
  • Vasospasms- Raynaud’s (poor arterial perfusion; increased r/f infection)
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9
Q

SLE Drugs for Altered Renal Function

A
  • Most commonly used drugs in anesthesia are at least partly dependent on renal excretion for elimination
    • Dose/frequency modification may be needed to prevent accumulation of drug OR active metabolites
  • Intravenous Agents
    • Pk of Propofol and Etomidate not significantly affected by renal impairment (OK)
    • Benzos undergo hepatic metabolism and conjugation prior to elimination in urine (OK)
    • Opioids: accumulation of morphine and meperidine metabolites prolong respiratory depression in some renal failure
  • VA’s – ideal d/t lack of dependence on kidney for elimination
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10
Q

Myasthenia Gravis Anesthesia Considerations

A
  • Elective surgery during remission
  • Premed/opioids minimized or avoided
    • Prone to weakness
    • Aminoglycoside antibiotics can enhance weakness
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11
Q

Muscular Dystrophy Anesthesia Considerations: Induction

A
  • Succinylcholine contraindicated
    • Risk of inducing severe hyperkalemia, rhabdomyolysis, v-fib and cardiac arrest
    • MH risk: Unclear if true MH or “MH like” rxn w/ rhabdomyolysis etc.
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12
Q

Myasthenic Syndrome or Myasthenia Gravis?

Sensitive to Sch and NDMR

A

Myasthenic Syndrome

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13
Q

Stress Dose Steroids in Periop Setting

A
  • If pt already on steroids, continue at usual dose if possible
  • Data supporting administration of stress doses limited, decision to administer depends on procedure
  • Small procedures (dental work, skin biopsies):
    • no stress dose necessary
  • Moderate procedures:
    • give 25 mg hydrocortisone q8hr, taper over 1-2 days
  • Major surgery:
    • give 50 mg hydrocortisone q8hr, taper over 2-3 days
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14
Q

SLE Manifestations: Joints/Muscle

A
  • Symmetrical arthritis (90%)
  • Cricoarytenoid arthritis
  • AVN (avascular necrosis)– can lead to pain
  • Myopathy
  • Tendon ruptures
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15
Q

Scleroderma multi-system effects: ENT

A
  • dry eyes
  • dry mouth
  • oral/nasal tanglectasias (r/f bleeding)
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16
Q

Myasthenic Syndrome: Anesthesia Considerations

A
  • May be undiagnosed… suspect in bronchoscopy. Mediastinoscopy, or thoracoscopy for suspected lung CA.
  • Unlike myasthenia gravis, LEMS pts are very sensitive to both depolarizing (Sch) and NDNMB’s
    • Anticholinesterase drugs not helpful in this dz and may not effectively reverse clinical effects of NDMR because defect is pre-synaptic
  • VA’s alone often sufficient to provide muscle relaxation for intubation and most surgical procedures
  • Only give NMBA’s in small increments and w/ careful neuromuscular monitoring
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17
Q

Ankylosing Spondylitis Clinical Manifestations:

Cardiac involvement

A
  • Aortic regurgitation (avoid sudden↑ in SVR/ keep HR >90 bpm/low normal BP)
  • Conduction abnormalities- BBB
  • Cardiomegaly
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18
Q

Myasthenic Syndrome or Myasthenia Gravis?

Muscle pain common

A

Myasthenic Syndrome

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19
Q

Muscular Dystrophy–Duchenne’s/Pseudohypertrophic:

Clinical Manifestations: Other musculoskeletal

A

Progressive and severe kyphoscoliosis that results from progressive weakness and contractures

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20
Q

SLE Manifestations: Lungs

A
  • “Lupus pneumonia”
  • Restrictive pattern
  • Recurrent atelectasis (Phrenic nerve neuropathy)

Chart: pleuritis, pneumonitis, PE, pulm hemorrhage

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21
Q

Muscular Dystrophy–Duchenne’s/Pseudohypertrophic:

Clinical Manifestations: GI

A
  • Reduced intestinal tract tone
    • Delayed gastric emptying and ↑ r/f aspiration
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22
Q

Marfan’s Syndrome: Clinical Manifestations (other than CV)

A
  • Long tubular bones: long legs/arms/fingers
  • Hyperextensibility of joints
  • High arched palate (difficult intubation)
  • Crowded teeth
  • Pectus excavatum
  • Kyphoscoliosis
  • Pulmonary
    • High incidence PTX
    • Spinal/ sternal deformities –> restrictive lung
  • Ocular
    • Dislocation of ocular lens; Retinal detachment
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23
Q

Muscular Dystrophy–Duchenne’s/Pseudohypertrophic:

Clinical Manifestations: Cardiopulmonary dysfunction

A
  • Degeneration of cardiac muscle
  • Chronic weakness of inspiratory muscles = ↓ ability to cough/clear secretions
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24
Q

RA Additional Clinical Manifestations: Pulmonary

A
  • Pleural effusion and restrictive lung dz d/t rheumatoid nodules in lung tissue
  • ↓ lung volume
  • Pulmonary fibrosis (rare)
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25
Q

Myasthenia Gravis: Patho

A
  • Autoimmune destruction of postsynaptic Ach receptors at NMJ (up to 80% loss)
  • Characterized by weakness & rapid exhaustion of skeletal muscle
    • Particularly those innervated by cranial nerves (ocular, pharyngeal, laryngeal) – eye drooping, r/f dysphagia and aspiration
  • Course marked by exacerbations & remissions
  • 1:7500 (women age 20-30 and men >60)
  • Surgery, infection, stress, and pregnancy often lead to exacerbations
  • Association w/ thymic hyperplasia and thymoma
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26
Q

RA: Management of Anesthesia

A
  • Anemia of chronic disease
  • Effect of meds on platelet function
  • With lung dz – PFT/ intraop ABG/post-op ventilatory support
  • May need stress dose corticosteroids
  • Extubate w/ caution if cricoarytenoid arthritis present (d/t post-extubation swelling)
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27
Q

Myasthenic Syndrome or Myasthenia Gravis?

Co-existing pathologic condition of thymoma

A

Myasthenia Gravis

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28
Q

Myasthenic Syndrome or Myasthenia Gravis?

Proximal limb weakness (legs more than arms)

A

Myasthenic Syndrome

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29
Q

OA Anesthetic Considerations: Positioning/drugs/etc.

A
  • Positioning: Support affected joint(s) and minimize r/f injury
  • Drugs used in treatment
    • Corticosteroids NOT recommended
    • NSAIDs and ASA → Potential bleeding issues
  • Reconstructive joint surgery → Total hip or knee replacement
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30
Q

Myasthenic Syndrome or Myasthenia Gravis?

Muscle pain uncommon

A

Myasthenia Gravis

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31
Q

SLE Anesthesia Considerations: Anesthesia management and drug selection

A
  • Interactions w/ drugs used in SLE treatment
  • Degree of organ dysfunction
    • Impaired renal
    • Hepatic clearance of drugs
    • Cardiopulmonary involvement
  • Strict asepsis w/ invasive procedures
    • ↓ r/f infection
  • Maintenance of normothermia
    • May ↓ r/f infection
    • Lessening impact of Raynaud’s if present
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32
Q

SLE Manifestations: Kidneys

A

Glomerulonephritis leading to nephrotic syndrome and renal failure

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33
Q

Myasthenic Syndrome or Myasthenia Gravis?

Co-existing pathologic conditions of small cell lung cancer

A

Myasthenic Syndrome

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34
Q

Scleroderma multi-system effects: Renal

A

renal HTN (ACE inhibitors are effective)

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35
Q

Muscular Dystrophy–Duchenne’s/Pseudohypertrophic:

Clinical Manifestations: Cardiac

A
  • Cardiac muscle degeneration
    1. ECG abnormalities
      • Atrial arrhythmias
      • Prolonged PR interval
    2. ↓ myocardial contractility and cardiomyopathy
    3. Mitral regurgitation 2º to papillary muscle dysfunction
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36
Q

Muscular Dystrophy Anesthesia Considerations: Maintenance

A
  • Marked cardiopulmonary depression may be seen w/ VA’s
  • Normal to prolonged response to NDMR
  • Anticipate post-op pulmonary dysfunction
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37
Q

Myasthenic Syndrome or Myasthenia Gravis?

Reflexes normal

A

Myasthenia Gravis

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38
Q

SLE Manifestations: Skin and membranes

A
  • Butterfly rash w/ nasal erythema (50%)
  • Oral and pharyngeal ulcers
39
Q

Muscular Dystrophy–Duchenne’s/Pseudohypertrophic:

Clinical Manifestations–hallmark

A
  • Clinical hallmark is muscle weakness pronounced in proximal extremities
    • Wheelchair confined by age 8-10; Often fatal by 20.
40
Q

Ankylosing Spondylitis Clinical Manifestations:

Airway Considerations

A
  • Difficult intubation is associated when AS involves the c-spine
    • Increased difficulty d/t limited mouth opening when TMJ involved
  • Significant r/f neurological injury w/ any excessive neck extension
  • Progressive kyphosis and spine fixation may limit intubation
  • Risk of occult cervical fracture w/ minimal trauma
  • Cricoarytenoid arthritis
    • Cords susceptible to trauma (use small ETT and consider awake fiberoptic intubation)
41
Q

SLE Manifestations: Airway

A
  • Laryngeal involvement in ~ 1/3 pts
    • Mucosal irritation
    • Cricoarytenoid arthritis
    • Recurrent laryngeal nerve palsy (hoarseness, dysphagia)
42
Q

Myasthenic Syndrome or Myasthenia Gravis?

Exercise causes fatigue

A

Myasthenia Gravis

43
Q

SLE Manifestations: Inflammation and vasculitis

A
  • Vessel wall thickening, weakening, narrowing, and scarring: CAD, Stroke risk, etc.
  • HTN
  • +/- Pulmonary HTN– avoid high CO2 because it can cause vasoconstriction→ lead to acute RHF
  • Thromboembolism, Hypercoagulable state
  • Hemolytic anemia
  • Frequent fevers
44
Q

Muscular Dystrophy
Duchenne’s/Pseudohypertrophic

A
  • Most common and severe form of MD
    • Other dystrophies are less severe, onset at a later age, slower progression
  • Almost exclusively male and presents at age 2-5 yrs.
  • Characterized by symmetric proximal muscle weakness manifesting in gait disturbance
  • Pelvic girdle
  • Pseudohypertrophic: fatty infiltration
45
Q

Severe SLE Treatment

A
  • High-dose corticosteroids (Stress dose?)
  • Immunosuppressive/chemotherapy drugs
    • Methotrexate, cyclophosphamide, azathioprine, mycophenolate
46
Q

Rheumatoid Arthritis

A
  • Chronic, systemic inflammatory disorder/auto-immune w/ articular & systemic involvement
  • Characterized by exacerbations and remissions
  • Affects about 1% of adults (females > males)
47
Q

SLE Anesthesia Considerations: Airway management

A
  • Laryngeal involvement
    • Laryngeal erythema and edema common
    • Mucosal ulceration→ pain, bleeding
    • Cricoarytenoid arthritis
    • Recurrent laryngeal nerve palsy→ r/f aspiration
48
Q

Ankylosing Spondylitis Anesthesia Considerations

A
  • Anesthetic management influenced by severity of disease
    • Upper airway involvement
    • Presence of restrictive lung disease
    • Degree of CV involvement
    • May be using neurologic monitoring during corrective spinal surgery (anesthetic limitations)
  • Awake fiberoptic tracheal intubation if spinal deformity extensive
  • Spinal and epidural anesthesia is technically difficult
    • May result in an increased risk of complications
    • Consider paramedian approach
49
Q

Scleroderma multi-system effects: CNS

A
  • Thickened connective tissue around nerve sheath leading to neuropathy; high incidence trigeminal neuralgia
50
Q

Myasthenic Syndrome: Patho

A
  • Lambert-Eaton myasthenic syndrome (LEMS)
  • Develops in association w/ a neoplasm, but also seen w/ other occult malignancies or idiopathic autoimmune
    • Usually small cell lung CA
  • Disorder results from presynaptic side defect of neuromuscular transmission
  • IgG Antibodies form against the presynaptic voltage gated Ca++ channels = ↓ release of Ach
  • If tumor present, antibodies are directed at tumor but cross-react w/ Ca++ channels
51
Q

SLE Anesthesia Considerations: Neuraxial and regional nerve blocks

A
  • Currently taking anticoagulants or known coagulopathy?
  • Presence of a peripheral nerve lesion?
52
Q

Osteoarthritis Clinical Features

A
  • Degenerative changes are most significant in middle/lower cervical and lower lumbar
    • Associated protrusion (herniation) of nucleus pulposus (slipped disk) resulting in nerve root compression
  • Occurs in weight bearing joints or in conditions that put undue stress on joints
    • Obesity
    • Joint deformity
53
Q

OA Anesthetic Considerations: Pneumatic Tourniquets

A

Pneumatic Tourniquets

  • Provides bloodless field that greatly facilitates surgery
  • Inflation pressure ~ 100 mmHg over SBP
    • Prolonged inflation (>2h) = pain, nerve damage
    • Be careful not to over-administer opioids for tourniquet pain!
  • Deflation
    • Hemodynamic changes (↑CO2 and hypotension with “wash-in”)
    • Washout of accumulated metabolic wastes
54
Q

Myasthenic Syndrome or Myasthenia Gravis?

Extraocular, bulbar, and facial muscle weakness

A

Myasthenia Gravis

55
Q

Achondroplasia

A
  • Most common cause of Dwarfism
  • Caused by premature ossification of bones combined w/ normal periosteal bone formation
    • Results are characteristic appearance of short limbs and relatively normal cranium
  • Often present to OR for sub-occipital craniectomy for foramen magnum stenosis, laminectomy (spinal stenosis/nerve root compression), VP shunt
    • Consider need for VAE monitoring (VAE sitting crani)
    • Evoked potential monitoring (limits anesthetic options)
56
Q

Marfan’s Clinical Manifestations: CV

A
  • Aortic aneurysm and dissection remain most life-threatening manifestations (↑ risk in pregnancy)
  • Cardiac Valve Prolapse/dysfunction/regurg
    • Mitral Valve
    • Aortic valve – incompetence often related to dilation of ascending aorta
  • Arrhythmias- BBB
  • Aortic and atrioventricular valves prone to calcification
57
Q

Scleroderma

A
  • Inflammation & autoimmunity, vascular injury, fibrosis
  • Females
  • Pregnancy may accelerate symptoms
  • Unknown etiology; no treatment available
  • Can lead to CREST syndrome
    • Calcinosis, Raynaud phenomenon, Esophageal hypomotility, Sclerodactyly, Tanglectasia
58
Q

Myasthenia Gravis Anesthesia Considerations: Maintenance

A

Deep anesthesia w/ VA can provide sufficient relaxation for many sx procedures

59
Q

Scleroderma multi-system effects: Musculoskeletal

A
  • Myopathy
  • Proximal skeletal muscle weakness
60
Q

Lupus (SLE) Manifestations: CNS

A

1/3 of pts have cognitive symptoms (can be vague; agitation)

61
Q

Myasthenic Syndrome or Myasthenia Gravis?

Resistant to Sch, sensitive to NDMR

A

Myasthenia Gravis

62
Q

Myasthenia Gravis: Treatment

A
  • Usually oral anticholinesterase +/- steroid therapy
    • Cholinesterase inhibitors – PO Pyridostigmine
      • Onset 30 min, peak 2 hrs, DOA 3-6 hrs
      • Higher doses paradoxically enhance muscle weakness- “cholinergic crisis”
    • Corticosteroids – Prednisone limits antibody production (second line therapy after failure of above)
  • Thymectomy – surgical approach
    • Median sternotomy or mediastinoscopy
  • Plasmapheresis – removes antibodies during crisis (temporary)
    • Depletes plasma esterase levels
      • Prolonged effect of succ, mivacurium, ester-linked LA’s, etc.
63
Q

Myasthenic Syndrome or Myasthenia Gravis?

Reflexes absent or decreased

A

Myasthenic Syndrome

64
Q

Achondroplasia Anesthesia Considerations:

General (other than airway, cv, pulm)

A
  • Normal response to anesthetic agents and NMB
  • Difficult IV and CVC access
    • Short neck
    • Excess skin and SQ tissue
65
Q

Ankylosing Spondylitis Clinical Manifestations:

Pulmonary abnormalities

A
  • Pulmonary fibrosis
  • Apical cavity lesions
  • Pleural thickening (similar to TB)
  • Decreased compliance of chest wall
  • Decreased vital capacity
66
Q

Muscular Dystrophy–Duchenne’s/Pseudohypertrophic:

Clinical Manifestations: Respiratory

A
  • Respiratory muscle degeneration
    • Progressive respiratory muscle weakness
      • Inadequate cough and retention of secretions = Frequent pulmonary infections
    • Kyphoscoliosis and muscle degeneration → severe restrictive disease pattern
    • Sleep apnea common
      • Pulm HTN w/ disease progression
67
Q

Muscular Dystrophies

A
  • A range of congenital muscular disorders characterized by progressive weakness and degeneration of muscle
    • Affected individuals produce abnormal dystrophin
      • Protein found on the sarcolemma of muscle fibers
      • Increased permeability of skeletal muscle precedes symptoms
    • Painless degeneration
    • Atrophy of skeletal muscle
  • Classified according to inheritance
    • X-linked: Duchenne’s (pseudohypertrophic), Becker
    • Autosomal recessive: limb-girdle, congenital
    • Autosomal dominant: facioscapulohumeral, oculopharyngeal
68
Q

RA: Airway Evaluation and Management

A
  • Document pre-op ROM limits, baseline symptoms of pain, numbness, weakness
  • Consider awake fiberoptic intubation
  • Determine head positions awake that can be tolerated
  • Ask about tingling hands/feet, pain, assess ROM
  • Avoid excessive movements during laryngoscopy
  • Temporomandibular joint (TMJ)
    • Assess mouth opening, may be limited
    • TMJ w/ cervical spine immobility may limit DL visualization
  • Cricoarytenoid joints
    • Fixation may present as voice changes or hoarseness
    • Arthritis and inflammation can make glottic opening difficult to identify or stenotic
    • Cricoarytenoid arthritis = ↓ ETT size
    • Minimal edema may lead to airway obstruction postop
  • C-Spine
    • Atlantoaxial subluxation (AAS)
      • Distance b/t anterior arch of atlas to odontoid process >3mm on xray (during neck extension)
      • Occurs in 25% of severe RA pts
      • R/f cervical spinal cord/medulla compression by odontoid process and interference w/ vertebral artery blood flow
69
Q

Scleroderma multi-system effects: Pulmonary

A
  • Fibrosis
  • Restrictive pattern
  • ↓ compliance
70
Q

Achondroplasia Anesthesia Considerations:

Pregnant patient

A
  • C-section required
  • Cephalopelvic disproportion
  • Kyphoscoliosis and narrow epidural space, spinal canal, osteophytes, vertebral disk/body deformity increase technical difficulty
  • No evidenced based dosing guidelines (epidural might be better so that you can titrate LA slowly)
71
Q

Myasthenic Syndrome or Myasthenia Gravis?

Affects males more often than females

A

Myasthenic Syndrome

72
Q

Myasthenic Syndrome: Clinical Features

A
  • Presents w/ proximal muscle weakness
    • Typically begins w/ lower extremities, spreads to upper limbs, bulbar, respiratory muscles
    • Change in gait, ability to stand, climb stairs
    • Exercise improves strength
  • Autonomic dysfunction very common
    • Hemodynamic variability
    • Dry mouth
    • Urinary hesitancy improves with repeated effort
73
Q

Myasthenia Gravis Anesthesia Considerations: Induction

A
  • Short-acting agents (Propofol)
  • Consider intubation without muscle paralysis
    • Intubation w/ deep VA may be sufficient
    • Topical lidocaine application to airway
    • If must use NDMB, use PNS at orbicularis oculi (may overestimate block)
    • NDMB potency ↑ 2X: ↓dose 33-50% if using
  • Aspiration risk - consider RSI
    • Sch dose may be ↑ to 2 mg/kg to overcome resistance, but anticipate prolonged effect
    • If Sch used - do not use NDMR until muscle function has returned
74
Q

Muscular Dystrophy Anesthesia Considerations

A
  • Muscle weakness, CV & pulmonary involvement
  • Preop sedation/opioids best avoided
    • Respiratory muscle and laryngeal reflex weakness
    • Gastric hypomotility
  • Aspiration prophylaxis
    • Antacid with H2 blocker or PPI
    • Prokinetic like metoclopramide to ↓ volume
    • Antisialogogue like glycopyrrolate if sections are an issue
  • Positioning can be complicated by kyphoscoliosis and flexion contractures
  • Regional anesthesia may be preferable
75
Q

Myasthenia Gravis: Clinical Features

A
  • Presentation varies from mild weakness of limited muscle groups (class I or ocular MG) to severe weakness of multiple muscle groups (class IV or severe generalized MG)
  • Ocular muscles most commonly affected
    • Ptosis, dysphagia and diplopia (most common initial complaints)
  • Bulbar involvement/Laryngeal and pharyngeal muscle weakness
    • Difficulty clearing secretions → Pulm aspiration
  • Myocarditis possible
    • A-Fib, heart block, cardiomyopathy
  • Severe dz associated w/ asymmetrical proximal muscle weakness (no atrophy though)
    • Neck, shoulders, respiratory muscles
76
Q

Rheumatoid Arthritis: presentation

A
  • Symmetrical poly-arthritis in joints
    • Early disease
      • Hands, Wrists
      • Feet, Ankles
    • Later progression
      • Shoulders, Elbows, Knees
  • Temporomandibular joint (TMJ)
  • Cervical spine (atlantoaxial instability and cord compression)– keep a neutral spine; use video laryngoscope; let pt position themselves
77
Q

RA Treatment Options

A
  • Meds to treat pain and inflammation
    • ASA, NSAIDS (associated blood loss)
    • Corticosteroids (for acute periods only)
  • Surgical Treatment to relieve painandrestore joint function
    • Tendon release procedure, synovectomy, joint replacement
  • DMARDS – alter immune response, slow progression
    • Methotrexate (bone marrow suppression, cirrhosis)
    • Azathioprine
    • Sulfasalazine (anti-inflammatory, mild immunosuppressant)
    • Antimalarial drugs
    • Minocyclin
    • TNF inhibitors/monoclonal antibodies (de-myelinating syndromes, infection??)
78
Q

Achondroplasia Anesthesia Considerations:

Airway Management

A
  • Challenges with airway management
    • Facial features can lead to difficult mask management
      • Large protruding forehead, short maxilla w/ long mandible, flat nose, large tongue
    • Larynx may be small and intubation occasionally difficult
      • Difficult to expose glottis
      • Range of ETT sizes and difficult airway cart available
      • Weight rather than age is best guide for predicting proper size
    • Foramen magnum stenosis, fusion of the atlantooccipital joint with the odontoid, atlantoaxial instability, bulging discs, cervical kyphosis common
      • Avoid hyperextension during intubation
79
Q

RA Additional Clinical Manifestations: Cardiac

A
  • Dysrhythmia d/t rheumatoid nodules in cardiac conduction system
  • Cardiac valve fibrosis
  • Pericarditis
  • Myocarditis
  • Coronary artery arteritis
  • Dilation of aortic root- aortic regurgitation
80
Q

Osteoarthritis Pathogenesis

A
  • Commonly referred to as Degenerative Joint Disease (DJD), ‘wear and tear’
  • Hallmark is degeneration of articular cartilage
  • Most commonly hip and knee
  • Differs from RA in that there is minimal inflammatory reaction
81
Q

SLE Manifestations: Liver

A
  • Biliary cirrhosis
  • Autoimmune hepatitis
82
Q

Marfan’s Anesthesia Considerations:

CV and Pulm

A
  • Pre-op assessment should concentrate on CV abnormalities
  • Continue beta blockade peri-op
  • Continuously monitor for PTX
  • Hemodynamic Stability is critical
    • Prevent sudden ↑ in myocardial contractility as this produces an ↑ in aortic wall tension
    • Avoid excessive endogenous catecholamine production
      • Control pain and anxiety
      • Perform hemodynamic stable induction
    • Treat HTN immediately
    • VA’s can ↓ force of cardiac ejection = ↓ r/f aortic dissection
83
Q

Myasthenic Syndrome or Myasthenia Gravis?

Affects females more often than males

A

Myasthenia Gravis

84
Q

Ankylosing Spondylitis Treatment

A
  • Management of AS patients
    • Relieve pain, reduce inflammation, and maintain good posture and function
  • Traditional treatments include NSAIDs, education, exercise, and physical therapy
    • Exercise and PT to maintain joint mobility and flexibility
  • Early diagnosis/treatment essential to prevent permanent posture and mobility loss
  • Surgery considered in pts w/ severe, advanced dz associated w/ refractory pain and disability
85
Q

Marfan’s Syndrome: Treatment

A
  • Beta Blockers = standard of care
    • Reduce workload of heart
    • Delay/prevent aortic aneurysm and dissection
  • Surgical procedures
    • Elective surgery to repair aortic root recommended when maximum aortic diameter reaches 4.5 cm
    • Spinal fusion for scoliosis
86
Q

Marfan’s Anesthesia Considerations: Airway eval and management

A
  • Airway evaluation and management
    • High arched palate w/ crowded teeth
      • Visualization of larynx during DL rarely difficult
    • TMJ dislocation
      • Tendency for joint laxity
      • Avoid extreme movement of mandible
    • Tracheomalacia
      • Floppy tracheal cartilage leading to tracheal collapse
87
Q

What disease is characterized by symmetric proximal muscle weakness manifesting in gait disturbance?

A

Duchenne’s

88
Q

Myasthenic Syndrome or Myasthenia Gravis?

Poor response to anticholinesterases

A

Myasthenic Syndrome

89
Q

OA Anesthetic Considerations: Bone Cement

A
  • Bone Cement (polymethylmethacrylate or PMMA)
  • “Cement” misnomer (not bonding 2 things together). Space-filler creates tight space & holds implant against bone, more like ‘grout’.
  • Bone cement implantation syndrome (fat/marrow embolisms)
    • Hypoxia (increased pulmonary shunt)
    • Hypotension
    • Pulm HTN
    • Dysrhythmias (heart block and sinus arrest)
    • ↓ CO
90
Q

Myasthenic Syndrome or Myasthenia Gravis?

Exercise improves strength

A

Myasthenic Syndrome

91
Q

Marfan’s Syndrome

A
  • Multi-System disorder of connective tissue caused by mutations in extracellular matrix protein fibrillin 1
  • Typically involving CV, skeletal, and ocular systems: Classic manifestations include proximal aortic aneurysm, dislocation of ocular lens, long-bone overgrowth
92
Q

Systemic Lupus Erythematosus (SLE): Diagnosis

A
  • Antinuclear antibodies (95% of patients with SLE)
  • Nephritis
  • Rash
  • Raynaud’s
  • Serositis
  • Thrombocytopenia
93
Q

Scleroderma multi-system effects: GI

A
  • Dysphagia
  • Hypomotility of lower esophagus & small intestine
  • ↓ LES tone (r/f GERD)
  • Malabsorption
94
Q

Myasthenic Syndrome or Myasthenia Gravis?

Good response to anticholinesterases

A

Myasthenia Gravis

Coexisting (5 decks)

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