Neuro and neuromuscular assessment

Question 1

Basic Pathophysiology of MS

Answer 1

Diverse combinations of inflammation, demyelination and axonal damage in the CNS

-Loss of myelin followed by formation of plaques

-Peripheral nerves are not affected
Characterized by exacerbations and remissions

-Most common type: Primary-progressing
Unpredictable intervals

-Symptoms eventually persist leading to severe disability

Question 2

Etiology of MS

Answer 2

genetically susceptible persons
No clear genetic, environmental, or infectious causes have yet been identified
Triggering event, e.g. virus
Pregnancy reduces exacerbation, increased risk of relapse postpartum

Question 3

What are symptoms of MS from?

Answer 3

multifocal and always progressive, reflect sites of demyelination in the CNS

Question 4

What are clinical manifestations of MS

Answer 4

Motor weakness/spasticity: issues with gait
Sensory disorders: numbness/tingling
Visual impairment: optic neuritis, diplopia
Bladder and bowel dysfunction
Autonomic instability
Increased incidence seizure disorders
Hyperthermia can exacerbate symptoms
Emotional instability/depression

Question 5

How do you diagnose MS?

Answer 5

CSF and MRI

Question 6

What is Optic neuritis (seen in MS?)

Answer 6

diminished visual acuity and defective pupillary reaction to light.

Question 7

Main 5 symptom medications for MS?

Answer 7

Cortacosteroids, interferon, glatiramer, mitroxantrone, baclofen, methotrexate

Question 8

Concerns with cortacosteroids

Answer 8

Acute exacerbations covers both immune and inflammatory response

Question 9

Concerns with interferon?

Answer 9

Flu like symptoms. Alters inflammatory response, augments natural disease progression, may reduce relapse rates.

Question 10

Concerns with Glatiramer

Answer 10

Noninterferon, nonsteroidal immune modulator

Question 11

Big concern with Mitoxantrone

Answer 11

Severe cardiotoxicity
- functions as an immunosupressant

Question 12

Baclofen anestesia concerns

Answer 12

prolongs sedation
Increases sensitivity to NDMR

Question 13

Big concern for methotrexate

Answer 13

inhibits both cell-mediated an humoral response

Question 14

MS anestesia implications

Answer 14

Assess and document neurologic deficits
Consider diagnostic testing based on medical management: CBC, BMP, LFTs
Consider stress dose corticosteroids
Take all MS meds up until DOS
Symptoms may be exacerbated postoperatively, respiratory muscle weakness increase likelihood ICU ventilatory support
Temperature management: Avoid hyperthermia!!!

Question 15

What med do you avoid with MS in your anesthetic plan?

Answer 15

Avoid Succs Ch due to possible exaggerated release of K+

Question 16

other anesthesia MS considerations?

Answer 16

Judicious NMB, possible prolonged effects or resistance
SAB implicated in postoperative exacerbations MS
MOA local anesthetic neurotoxicity?
Epidural and peripheral nerve block OK
Inform patient of the risk of postoperative MS exacerbation

Question 17

ALS patho

Answer 17

Progressive, incurable degenerative disease of upper and lower motor neurons
Weakness/atrophy and eventual paralysis of upper/lower extremities
Bulbar palsy, dysphagia, trismus, laryngospasm
Respiratory compromise, aspiration risk, exquisitely sensitive to sedating medications (anesthesia)

Question 18

Etiology of ALS

Answer 18

Genetic, environmental, autoimmune, and viral

Question 19

Patterns of progression

Answer 19

Time of survival after Dx ~ 3-5 yrs
Death results from ventilatory failure 2o to neuromuscular weakness

Question 20

What is the one ALS disease modification drug?

Answer 20

Riluzole: Na channel blocker , may increase glutamate uptake and slow progression of cellular destruction, Issues with potential liver dysfunction

Question 21

Why do you usually see an ALS patient?

Answer 21

Palliative procedures: PEG, tracheotomy
Elective or semi-elective procedures scheduled early in the disease process

Question 22

Preop testing?

Answer 22

Guided by patients’ comorbidities
An electrolyte panel and assessment of renal function is reasonable if the patient has severely impaired swallowing, weight loss, and is at risk for dehydration.

Creatine phosphokinase is typically elevated due to chronic muscle wasting and should not raise concerns for myocardial injury.

Question 23

ALS Anesthesia Implications

Answer 23

Risk for dehydration, aspiration and respiratory compromise

Question 24

What med should be avoided?

Answer 24

Succs

Question 25

Myasthenia Gravis Patho

Answer 25

Antibodies attack the postsynaptic ACh receptor at NMJ
90% have thymic hyperplasia (10% with tumor involvement)
Often found with other autoimmune disorders (RA)
Proximal muscle weakness alleviated by rest, exacerbated by activity
Bulbar muscle involvement: dysphagia,
diplopia, and ptosis

Question 26

What is Osserman staging system?

Answer 26

Osserman’s original classification divides adult myasthenia gravis into four groups based on the severity of the disease.

Question 27

MG treatment

Answer 27

First-line therapy: Anticholinesterase medications (pyridostigmine) +/- glucocorticoids
Immunosuppressant agents
Plasmapheresis +/- IV Ig: severe bulbar and respiratory compromise
Thymectomy: Patients with thymomas, < 45 yo, + serum anti-AChR antibody

Question 28

Myasthenic crisis

Answer 28

exacerbation of disease

Question 29

Cholinergic crisis

Answer 29

anticholinesterase overdose

Question 30

What can you give in preop to decreas risk of post op myasthenia crisis?

Answer 30

High dose glucocorticoids

Question 31

What one test might you do for an elective surgery with MG

Answer 31

Cardiopulmonary work up if functional capacity, dyspnea, and fatigue.

Question 32

Ways you can address MG patients increased risk of aspiration

Answer 32

Aspiration prophylaxis with H2 antagonists and metoclopramide

Question 33

In MG patients are there a normal or low number of postsynaptic Ach receptors?

Answer 33

Lower

Question 34

What is inhibited by anticholinesterase medications?

Answer 34

Plasma cholinesterase

Question 35

What is the effect of nondepolarizing NMB agents?

Answer 35

Increased sensitivity

Question 36

What is the effect of depolarizing NMB?

Answer 36

reduced, and more resistant… yet MORE PORLONGED