Neurological Diseases in Anesthesia (Part 1) Flashcards
1
Q
__________________ is modulated by Cerebral Metabolic Rate (CMR), Cerebral Perfusion Pressure (CPP), PaCO2, PaO2, drugs and intracranial pathologies.
A
Cerebral Blood Flow
2
Q
CBF is ____ml/____g brain tissue per minute
A
- 50 ml/100g
3
Q
Cerebral Blood Flow (CBF) is _____ ml/min
A
- 750ml/min
4
Q
What percentage % of CO goes to Cerebral Blood Flow (CBF)?
A
- 15%
5
Q
Neural tissue (brain + spinal cord), blood, and CSF are all components of the _____________________ .
A
Intracranial and spine vault
6
Q
The Intracranial & Spinal vault is enclosed by ………..
A
- dura mater
- bone
7
Q
Under normal conditions, brain tissue, intracranial CSF and intracranial blood have a combined volume of ________ .
A
- 1200-1500 ml
8
Q
What is a normal ICP
A
- 5-15 mmHg
9
Q
____________________ is any increase in one component of intracranial volume must be offset by decrease in another component to prevent an elevated ICP.
A
Monroe - Kellie Hypthesis
10
Q
Hemostatic Mechanisms can increase MAP to support CPP despite increase in ICP. When these compensations fail, it results in?
A
Cerebral Ischemia
11
Q
What is shown in this graph?
A
Monroe- Kellie Hypothesis
12
Q
The intracranial vault is considered ________________.
A
- compartmentalized
13
Q
________ barriers seperate the brain contents
A
Meningeal barriers
14
Q
Name (2) Meningeal Barriers
A
- Falx cerebri
- tentorium cerebelli
15
Q
Name the dura that seperates the 2 cerebral hemispheres
A
- falx cerebri
16
Q
Name the dura that lies rostal to the cerebellum and marks the border btw supratentorial and infratentorial cerebelli
A
- tentorium cerebelli
17
Q
Increases in contents of one region of the brain causes regional _____ in ICP , and in extreme instance, the contents can herniate into a ________ __________.
A
- increases
- different compartments
18
Q
Herniation syndromes are categorized based on
A
- region of brain affected.
19
Q
Name the Herniation:
* Herniates Hemispheric contents under the falx cerebri
* compressing branches of the anterior cerebral artery
* creates a midline shift
A
Subfalcine Herniation
20
Q
Name the herniation:
* Herniation of supratentorial contents past the tentorium cerebelli
* brainstem compression in a rostal to caudal direction
A
Trantentorial Herniation
21
Q
_____________ Herniation can cause AMS, defects in gaze and occular reflexes, hemodynamic and respiratory compromise and death.
A
Transtentorial
22
Q
Name the Herniation:
* subtype of transtentirial herniation
* uncus hernates over the tenrorium cerebelli
* Results in ipsilateral oculomotor nerve dysfunction
A
Uncal Herniation
23
Q
_____________ Herniation symptoms are pupillary dilation, ptosis, lateral deviation of affected eye, brainstem compression and death.
A
Uncal
24
Q
Herniation of the ________________ can occur d/t elevated infratentorial pressure, causing cerenellar structure to herniate through the foramen magnum.
A
cerebellar tonsils
25
Hernaition of the ____________________can cause medullary dysfunction, cardiorespiratory instability and death.
cerebellar tonsils
26
Subfalcine causes a _________ shift.
*midline shift
27
Transtentorial Brain Hernation causes a ____________ down
* subrtentoial down
28
Cerebellar Herniation shifts contents through _________ ___________.
* formen magnum
29
Traumatic herniation can cause herniation out of ____________ cavity
* cranial
30
Tumors, Hematomas, blood in CSF and infections can all cause an ________ ICP
Increased
31
Tumors lead to an _____________ ICP with their size, _______ surrounding brain tissue and by __________ CSF flow.
* Increased
* edema
* obstructing
32
How can blood in CSF cause an increase ICP
* ex: Subarachnoid hemorrhage
* lead to obstruction of CSF reabsorption
* granulations
33
Name (2) Infections that can cause an increased ICP
* meningitis
* encephalitis
34
Elevation of head, hyperventilation, CSF drainage, hyperosmotic drugs, diuretics, corticosteroids, cerebral vascostricting anesthetics (propofol) and surgical decompression can call cause a ______________ ICP.
Decreased
35
Elevation of the Head decreases ICP by _______ jugular venous outflow.
* encouraging
36
hyperventilation causes a decrease in ICP by __________ PaCO2.
* lowering PaCO2
37
Name (1) way to drain CSF to decrease ICP
* External ventricular drain (EVD)
38
How can hyperosmotic drugs cause a decrease in ICP?
* increase osmolarity
* draws fluid across BBB
39
How can corticosteroids cause a decrease in ICP?
* decrease swelling
* enhances integrity of the BBB
40
These seven components are part of a _____________ Assessment:
* basic pathology for neurological disorder
* pt's history, symptoms and baseline deficits
* imaging and available neurological results
* pts current drug and treatments
* evaluate risks/benefits of various anesthetic options
* pre-op optimize patients condition prior to anesthesia
* clear pre-op documentation and rational for anesthesia pains
Neurologic
41
Name the cause of Multiple Sclerosis
* No know cause
42
___________ ___________ is a progressive, autoimmune demyelination of central nerve fibers.
Multiple Sclerosis (MS)
43
Onset of MS
* 20 -40 years
44
Name (5) Risk Factors for Multiple Sclerosis
* female
* 1st degree relative
* Epstein-Barr Virus (EBV)
* other Autoimmune disorders
* smoking
45
Multiple Sclerosis is characterized by periods of _______ and _________.
exacerbation and remissions
46
Name (3) Triggers for Multiple Sclerosis (MS)
* stress
* elevated temps
* postpartum periods
47
Symptoms of ______ __________:
* motor weakness
* sensory disorders
* visual impairments
* autonomic instabolity
* symptoms vary d/t site of demyelination
Multiple Sclerosis
48
There is no ________ for Multiple Sclerosis, but it can be treated with corticosteroids, ________________, and targeted antibodies.
* No Cure
* immune modulators
49
MS Pre-Op Considerations
* existing deficits
* PFT
* CBC, BMP, LFT
* Pre-Op Steroids
50
Why is temperature management important for MS?
* increase in body temp can exacerbate MS symptoms
51
Name (3) Anesthesia options for MS
* GA
* RA
* PNB
52
You want to avoid ________ in MS patients because of induced hyperkalemia d/t ____ N-ach receptors
* Succinylcholine
* upregulation N-ach receptors
53
____________________ is an autoimmune disorder with antibodies generated against N-ACH Receptors at skeletal muscle endplates.
Myasthenia Gravis
54
Myasthenia Gravis affects ________ muscles and is ________ with exercise.
* Skeletal Muscles
* Exacerbated with exercise
55
Myathenis Gravis can cause ________ and ________ when it involves the Ocular Nerve
* diplosia
* ptosis
56
Laryngeal/pharyngeal weakness, Repiratory insufficency and aspiration can occur with ________ involvement of Myasthenia Gravis?
Bulbar
57
Thymic-hyperplasia is common in ____% of MG
10%
58
Myasthenia Gravis Symptoms are exacerbated by
* pain
* insomnia
* infection
* surgery
59
Myasthenia Gravis can be treated with Ach-E ________ (pyridostigmine), immunosuppressive drugs, steroids, ______________ and IVIG.
* Ach-E inhibitors (pyridostigmine)
* plasmapheresis
60
Name (2) Types of Medications you need to use with caution in patient's w/ MG
* Paralytics: prolonged respiratory compromise
* Opioids: Respiratory compromise
61
What medication that you give an MG patient that will prolong Succinycholine and Ester LA's?
* Ach-E inhibitors
62
What do you need to counsel MG patients on before they have surgery?
* increased risk of needing post-op Respiratory support/ventilation
63
____________________ is a disorder that causes developement of antibodies against VG calcium channels.
Eaton-Lambert Syndrome
64
________ ________ can cause progressive limb-girdle weakness, dysautonomia, and oculobulbar palsy.
Eaton- Lambert
65
>60% of Eaton-Lambert cases area associated with
* small cell lung carcinoma
66
What Neurologic Disease is treated with:
* Selective K Channel blocker (3-4 diaminopyridine)
* Ach-E inhibitors
* immunologics (Azathiprine)
* steroids
* plasmapheresis
* IVIG
Eaton-Lambert
67
Name the Lab that you need to check for any patient who is taking the immunologic Azathioprine
LFTs
68
Name the medications that Lambert-Eaton Syndrome patient's are very sensitive
* Non-depolarizing NMB
* Depolarizing NMB
| more sensitive to ND-NMB than MG pts
69
Extreme caution needs to be use with what (2) classifications of medications with Lambert-Eaton patients?
* Parlytics
* opioids
70
What do you need to councel your Eaton Lambert Patients on before surgery?
* Need of post-op respiratory support until fully recovered from anesthesia
71
Name the prefered anesthesia for Lambert Eaton patients
* Regional > General
72
Muscular Dystrophy is a hereditary disorder of muscle fiber degeneration caused by the ________ of dystrophin-glycoprotein complex.
* breakdown
73
_________________ can lead to myonecrosis, fibrosis and skeletal muscle membrane permeability.
Muscular Dystrophy
74
How many types of Muscular Dystrophy exist?
* 6 types
75
Name the most common and severe form of Muscular Dystrophy
* Duchenne MD
76
Summarization of Duchenne MD:
* boys
* onset ____ years
* wheelchair bound by ____ years
* dead by ____ d/t cardiopulmonary complications
* onset 2-5 years
* wheelchair bound by 8-10
* dead by 20-25 d/t cardiopulmonary complications
77
Symptoms of _________________ include:
* progressive muscle weakness w/out motor/sensory abnormalities
* kyphoscoliosis
* long bone fragility
* respiratory weakness
* frequent pneumonia
* EKG changes
Muscular Dystrophy
78
Reason for an increased serum creatine kinase in MD patients.
* Muscle Wasting
79
________ syndrome can occur in MD patient when given succs and volatile anesthetics, that mimics Malignant Hyperthermia.
* Hypermetabolic Syndrome
80
Name the (4) conditions that Hypermetabolic syndrome can lead to
* rhabdomyolysis
* hyperkalemia
* Vfib
* cardiac arrest
81
How is Hypermetabolic Syndrome treated?
* Dantrolene
82
Name the preferred anesthesia for patients with Muscular Dystrophy and Duchenne
* Regional Anesthesia over General Anesthesia
83
If General Anesthesia has to be given to a patient with Muscular Dystrophy, what is your plan?
* TIVA and low dose rocuronium
84
Name the (4) Types of Myotonic Dystrophies
* Myotonia
* Mytonic Dystrophy
* Myotonia Congenita
* Central Core disease
85
_____________ is a prolonged contraction after muscle stimulation that is seen in several muscle disorders.
Myotonia
86
________________ ____________ is the most common type of myotonia and onsets in 20-30 years.
Myotonic Dystrophy
87
Myotonic Dystrophy Symptoms
* muscle wasting in face, masseter, hand and pre-tibial muscles
88
Name (3) specific muscle that Myotonic Dystrophy can affect
* Pharyngeal
* Laryngeal
* diaphragmatic muscles
89
____ % of Myotonic Dystrophy patients will have Mitral Valve Prolapse
20%
90
______________________ is a milder form that involves skeletal muscles only. It spares the smooth and cardiac muscles.
Mytonia Congenital.
91
________________ is very Rare and is characterizes by core muscles that lack mitrochondrial enzymes.
Central Cores Disease
92
Central Core Disease symptoms are _______ muscle weakness and ___________.
* Proximal muscle weakness
* scoliosis
93
Myotonias are triggered by ____________ and ___________ temperatures.
* stress
* cold temperatures
94
Treatment of Myotonic Dystrophyies
* No cure
* Quinine
* Procanamide
* Steroids
95
Anesthetic Considerations for Myotonic Dystrophies
* Cardiac and pulmonary abnormalities
* GI hypomotility -↑aspiration risk
* Keep pts warm
96
Myotonic Dystrophies are at a higher Risk for ________ abnormalities
* endocrine
* monitor thyroid and glucose levels
97
Why would you avoid Succinylcholine in Myotonic Dystrophies
* fasciculations trigger myotonia
98
Myotonic Dystrophy patients are at an increased risk of what post-op?
* Respiratory Weakness
99
Name (3) Major Dementia Syndromes
* Alzeheimers (70%)
* Vascular Dementia (25%)
* Parkinsons (5%)
100
Dementia patient's might have issue giving consent for surgery. What should you look for in their charts?
* medical PoA
* Advance Directives
101
Name (3) medications a patient with Dementia might be on that can affect anesthetics
* AchE-I
* MAOI's
* psych meds
102
Why would you consider a TIVA for Dementia patient's?
* ↑risk for post-op delirium with general anesthesia
103
What are Dementia patient's at a high risk for during intubation?
* Aspiration
104
What are we trying to avoid post-op by balancing anesthetics and opiods through Regional anesthesia or TIVA?
* Post-Op delirium
105
_________________ is a degeneration of dopaminergic fibers of basal ganglia.
Parkinsons Disease
106
_________ regulates extrapyramidal motor system, which is stimulated by ACH and inhibits excess stimulation.
Dopamine
107
The cause of Parkisons Disease is ______, but the biggest risk factor is _______ ____.
* Unknown Cause
* Advance age is the biggest risk factor
108
Skeletal Muscle tremors, rigidity and akinesia are the Triad of Symptoms associated with ___________________.
*Parkinsons Disease.
109
Motor neurons in Parkinson's Disease are overstimulated and lack __________.
* lack Dopamine
110
Below are the classic symptoms of _____________.
* Rhythmic pill rolling
* facial rigidity
* slurred speech
* difficulty swallowing
* respiratory difficulty
* depression
* dementia
Parkisons
111
Treatment for Parkinson's Disease includes ___________ (crosses BBB), anticholinergics, MAOIs and __________________.
* Levadopa (crosses BBB)
* Deep Brain stimulator
112
Parkinson's Pre-anesthesia testing
* pulmonary compromise
* home meds
* labs w/ PFTs
* EKG and ECHO
113
Parkinson's patient are at an increased risk of ___________ during intubation due to _________ and possible _______________
* aspiration
* dysphasia
* dementia
114
Name the Parkinson's Medication that needs to be continued to avoid unstable extreme extrapyramidal effects such as chest wall rigidity
* PO Levadopa
115
Name (4) Medications to avoid in Parkinson's patients.
* Reglan
* Phenothiazines
* Butyrophenones
* Demerol -- if on MAOI
116
If your patient has a deep brain stimulator and cautery needs to be used, you should _________ the deep brain stimulator and use a ________ cautery.
* disable
* Bipolar cautery
