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Advance principles I, Exam 2 > Neurological disorders > Flashcards

Neurological disorders Flashcards

0
Q

Myocardial failure/dysfunction w/myopathic diseases

List

A

Muscular dystrophy
Cardiac muscle directly affected
CHF
Complex cardiac dysrythmias

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1
Q

The most sensitive indicator of autonomic cardiac involvement is

A

Loss of Beat to beat variability

Resting tachycardia, hemodynamic instability, dysautonomia (no beat to beat variability)

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2
Q

What suggests profound weaknesss of the diaphragm?

A

Paradoxical upward motion of the abdomen during inspiration

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3
Q

Pre op assessment of respiratory system

A

Respiratory pattern
Respiratory assessment
SOB
Orthopnea

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4
Q

Pulmonary function test

A
  1. FVC: Good estimate of ventilatory muscle strength & chest wall compliance
  2. Inspiratory force measurements
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5
Q

What are the signs of autonomic dysfunction?

A 
Orthostatic hypotension
Resting tachycardia
Paralytic ileus
Anhidrosis (lack of perspiration)
Constricted pupils
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6
Q

Adrenergic active anesthetic

A

Ketamine

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7
Q

Where is cardiomyopathy common and what is the best tool of suspected cardiac involvement?

A

Common in dystrophies

EKG best tool

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8
Q

What is common with dystrophies?

A

Cardiomyopathy
LV dysfunction
Mitral valve prolapse
Papillary muscle dysfunction

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9
Q

What are nutritional considerations

A

Hypoalbuminemia
Anemia
Hypocalcemia

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10
Q

When does up regulation of cholinergic receptor sites can be seen?
Hyperkalemia pt

A
  • As soon as 4 days after injury

- 3 weeks after acute denervation injury

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11
Q

Duchenne’s muscular dystrophy pathophysiology & facts

A
  • Sex linked recessive trait- boys 2-5 years old
  • Painless degeneration, atrophy of muscles, ,
  • Sensation & reflexes are intact – no denervation
  • infiltration of fibrous & fatty tissue into the muscle
  • abnormal dystrophin, increased plasma CK-increased muscle permeability
  • death due to CHF & pneumonia
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12
Q

Which muscular dystrophy has the most severe clinical course?

A

Duchenne’s muscular dystrophy

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13
Q

Cardiac effects - duchenne’s

A

Occurs in almost all pt, r/t cardiac muscle loss

  • cardiomyopathy - decreased contractility
  • Mitral regurg r/t papillary muscle dysfunction
  • vent dysrythmias
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14
Q

Pulmonary effects - duchenne’s

A
  1. Chronic respiratory muscle weakness
  2. Decreased cough & inability to clear secretions
  3. Sleep apnea
  4. Kyphoscoliosis restrictive lung physiology
  5. FVC <30% predicts post op complications
  6. Delayed pulmonary insufficiency up to 36 hrs
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15
Q

Main point for anesthetic consideration when thinking about meds

Muscles and heart/lungs in Duchenne’s dystrophy

A

Increased muscle permeability:
—rhabdo w/VA & sux-high K, cardiac arrest
—increased incidence of MH/prolong response w/NDMR
Decreased cardiopulmonary reserve
—delayed pulmonary insufficiency up to 36hrs

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16
Q

Anesthetic considerations for Duchenne’s

A
  1. Regional is best
  2. Extreme sensetivity to respiratory depression
  3. NO SUX
  4. Prolong response to NDMR
  5. Sensitive to myocardial depressants
  6. Increased “MH like symptoms” r/t inhaled agents
  7. Increased aspiration
  8. NO for OUTPATIENT surgery
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17
Q

What’s the most common chronic inflammatory arthritis?

Most common in ….

A

Rheumatoid arthritis

Women

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18
Q

Keraconjunctivitis is common in …

A

Rheumatoid arthritis : 10%

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19
Q

Cardiopulmonary effects of RA

A

Peri & myocarditis, rheumatoid nodules in cardiac conduction system
Pericardial effusion 1/3 of pt
Pleural effusion may mimic TB or CA on chest x ray
Pulmonary fibrosis – hypoxia

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20
Q

RA joint involvement

A
  1. Synovitis TMJ
  2. Thoracic & lumbosacral r NOT affected
  3. Cervical spine, upper: Atantoaxial subluxation & subsequent separation of the atlantoodontoid articulation - pressure on spinal cord & impair blood
  4. Cricoarytenoid arthritis: hoarseness, stridor, dyspnea
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21
Q

Antirheumatoid drugs

A

DMARDS first line of Rx

  1. Methotrexate once a week, chemo med - decreases inflammation
  2. Remicaide, enbrel
  3. NSAIDS: Celebrex, indocin

Mono therapy unlikely to be completely successful

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22
Q

Which disease effect cricoarytenoids?

A

RA

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23
Q

RA and anesthesia

A

TMJ mobility
Presence of stridor
Evaluate cervical spine

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24
Q

What is common cause of death in RA pt?

A

Renal secondary to vasculitis, amyloidosis, & anti rheumatic drugs

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25
Q

SLE incidence

A
  • Young females: African/Asian, slow acetylators
  • Exacerbated by STRESS
  • May be drug induced: PCN, methyl dopa, hydralazine, isoniazid, etc
  • Poor prognosis w/nephritis & HTN
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26
Q

SLE patho & s/s

A
  • -Chronic multisystem autoimmune disorder w/antibodies against DNA, RNA, cardiolipin, Ribosomal phospoproteins: antinuclear antibodies >95% of patients
  • -arthralgia, maculopapular rash, fever, anemia, leukopenia, thrombocytopenia
    • articular or systemic involvement
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27
Q

SLE articular involvement

A

Arthritis

—Avascular necrosis of the head or condyle of the femur

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28
Q

SLE systemic manifestations

A
  • -Pericarditis, CHF, valvular abn, restrictive pul disease, PUL ANGITIS (lung hemorrhage)
  • glomerulonephritis most common renal
  • pneumonia
29
Q

Glomerulonephritis, common in what diesase?

30
Q

What treatment for SLE?

A
  • NSAIDS: mild
  • corticosteroids: mod
  • immunosuppressants: cyclophosphamide (inhibits plasma cholinesterase, may prolong SUX) azathiprine, myophenolate mofetil
31
Q

SLE anesthetic management

A
  • consider system involvement

- AV shunt, PD cath, ortho procedures

32
Q

What is myasthenia gravis?

A

Chronic Autoimmune disease involving NM junction with antibodies directed against post synaptic Ach receptors.

Decrease # of functional post synaptic Ach receptors

33
Q

What is the hallmark of MG?

A

Weakness and exhaustion of voluntary, skeletal muscles w/repetitive use: eyelids
Improves with rest

34
Q

What disease is associated with Epstein Barr virus?

35
Q

What disease is associated with thymus gland abnormalities?

A

MG - hyperplasia in 70% of pts

75% undergo remission w/thymectomy

36
Q

What other autoimmune disorders is MG associated with?

A

Hypo/hyperthyroidism

RA

37
Q

What nerves usually effect MG

A

Cranial nerves: ptosis, diplopia are initial symptoms

38
Q

What are s/s of MG?

A

Ptosis, diplopia
Laryngeal/pharyngeal weakness=dysphasia, difficulty w/PO secretions
Cardiomyopathy, dysrythmias, a-fib, AV block

39
Q

Medication Rx for MG

A
  1. Anticholinesterase drugs: increase Ach at NMJ
    - neostigmine 15 MG PO
    - pyridostigmine 60 MG PO weaker, mild disease
  2. Corticosteroids: reduce AchR antibodies levels- 80% remission
    - prednisone
  3. Immunosuppressant: interfere w/production of AchR AB
    - azathioprine (Imuran)
    - mycophenolate (cell cept)—NEW
40
Q

What are the procedures for MG?

A
  1. Plasmapheresis: reduce concetration of circulating ABs
    - decreases time to extubation if done pre op
  2. Thymectomy: removing the source of AB production
    - 75-96% of pts improve
    - first line of Rx
41
Q

What are the criteria for post op intubation?

MG patient

A
  1. MG duration >6 years
  2. Presence of COPD
  3. Dose of pyridostigmine > 750mg/day
  4. Pre op VC <2.9 L
42
Q

Induction of MG pt

A
  1. Consider intubation without muscle relaxants
  2. VA are good for induction, tracheal intubation
  3. SUX resistant, 1.5-2 MG/kg for intubation
  4. NDMR sensitivity = no pretreatment, low & slow, PNS is a must
43
Q

What meds should be avoided for MG, pre op eval?

A

Ca channel blockers & Aminoglycosides

Both can exacerbate weakness

44
Q

Maintenance for MG during surgery

A
  1. VA
  2. Reduce NDMR by 1/2 to 2/3 titration is a key!
  3. Prolong effects of narcotics, induction agents, tranqulizers
  4. Regional > General
45
Q

Emergence of MG pt with reversal drugs…..

A

Careful with reversal- over Rx can precipitate cholinergic crisis

46
Q

Which LA are better and why?

A

Amides metabolized by liver

47
Q

Myasthenic crisis

A 
Not enough Ach
Give endrophonium ( short acting Acetylcholinesterase inhibitor) 1-2mg = improves symptoms
48
Q

Pulmonary ANGITIS associated with ….

49
Q

Cholinergic crisis

A

Too much Ach: skeletal muscle weakness r/t depolarizing like block with muscarinic like symptoms (cramps, diarrhea, mitosis, bradycardia & resp distress).

Give endrophonium 1-2mg
Worsening symptoms- cholinergic

50
Q

Which disease is associated w/ increase CK?

A

Duchenne’s

51
Q

Poor prognosis with nephritis and HTN

52
Q

PCN, methyl dopa, hydralazine, isoniazid, etc can induce….

53
Q

Which NM disorder has MH like symptoms

.

A

Duchenne’s disorder

54
Q

delayed pulmonary insufficiency up to 36hrs

A

Duchenne’s disorder

55
Q

Eaton-Lambert syndrome

Pathophysiology

A

Auto-Antibodies directed against presynaptic Ca channels - leads to decrease release of Ach @ NMJ– muscle weakness

56
Q

Characteristics of E-L Myasthenic syndrome

A
  • -Muscle weakness, fatigue, hyporeflexia, involving diaphragm & respiratory muscles
  • -ANS dysfunction: impaired gastric motility, ortho static hypotension, urinary retention
  • -Increased strength with exercise,
  • -No improvement with anti cholinergic agents
57
Q

Which disease is characterized as paraneoplastic syndrome?

A

Eaton-Lambert MYastatic syndrome

Lung cancer
Sarcoidosis, auto-immune disease, metastatic cancer

58
Q

Anesthesia consideration with Eaton-L syndrome

A

Sensitive to BOTH Sux & NDMR

Consider comorbidities: cancer…

59
Q

Rx for E-L syndrome

A

3,4 diaminopyridine
Plasmapheresis
Immunosuppressants
Corticosteroids

60
Q

Multiple sclerosis

Pathophysiology

A
  • -Inflammation & demyelination in the brain/spinal cord.

- -T cells are activated by virus, cross BBB- demyelination of corticospinal tract neurons starts

61
Q

Diagnosis of MS

A

Increased IGg in CSF

MRI shows location of plaque and lesions

62
Q

Rx of MS

A

Symptoms only no cure!
Steroids to Rx acute attack
Immunosuppression or interferon
Anti spastic drugs: backlofen, diazepam, dantrolene

63
Q

Anesthesia for pt with MS

A 
Avoid SAB, SUX if immobile
GA most common
Epidural OK  bupivicane <.25%
NDMR  sensitivity
VA/narcotics are best
64
Q

Biggest maintenance concern with MS

A

Normothermia

65
Q

Anesthetics implications for pt w/Parkinson’s

A
  1. Continue meds thru DOS levodopa t1/2=6-12hr interruption severe skeletal rigidity that could impair ventilation during surgery
  2. AVOID: phenotizines (compazine & phenegran) & butylphenones can antagonize the effects of dopamine in the basal ganglia
    3 AVOID: droperidol, metoclopramide
  3. Ketamine ? .? .?.Possible exaggerated SNS responses
66
Q

Rx for Parkinson’s

A

Goal to increase dopamine level

  1. Levodopa: can cross bbb, 4-6g/day
  2. Anticholinergic: cogentin, artane,
  3. Deep brain stimulators: DBS
67
Q

S/S of levodopa

A

Cardiac irratibility, ortho hypo,
Can deplete norepinephrine stores in heart
Increased contractility & HR

68
Q

Parkinson’s

Pathophysiology

A

Adult onset characterized by the loss of dopaminergic fiber normally present in the basal ganglia of the brain and don’t oppose action of Ach

69
Q

Which disease is SUX resistant?

Advance principles I, Exam 2 (5 decks)

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