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Assessment 2 > Preop Neruo Eval (1) > Flashcards

Preop Neruo Eval (1) Flashcards

1
Q

Three identified risk factors for preoperative stroke:

A

History of stroke or TIA
Advanced age
Pre-existing renal disease

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2
Q

Independent Predictors of Perioperative Stroke (12)

A

~ Atrial fibrillation
~ Valvular cardiac disease
~ Heart failure
~ Diabetes mellitus
~ Female gender
~ MI within 6 months
~ Prior cardiac intervention
~ Current dialysis
~ Acute renal failure (acute or chronic disease)
~ COPD
~ Current smoker
~ Hemiplegia

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3
Q

Chads Vas score

A

~ Congestive heart failure/LV dysfunction (1)
~ Hypertension (1)
~ Age >75 (2)
~ Diabetes Mellitus (1)
~ Stroke/TIA/ Thromboembolism (2)
~ Vascular disease (1)
~ Age 65-74 (1)
~ Sex (female) (1)

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4
Q

Chads Vas Scoring =

A

Adjusted stroke rate (% per year) with 95% confidence interval
0 = 1.9 (1.2-3.0)
1 = 2.8 (2.0-3.8)
2 = 4.0 (3.1-5.1)
3 = 5.9 (4.6 -7.3)
4 = 8.5 (6.3-11.1)
5 = 12.5 (8.2-17.5)
6 = 18.2 (10.5-27.4)

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5
Q

Bruits associated with symptomatic carotid disease need?

A

Further workup (carotid arteriography is the gold standard but ultrasound is faster and less invasive)

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6
Q

Aneurysms and AVMs

A

Usually found incidentally - 3.2% incidence worldwide, only 0.25% rupture

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7
Q

Myasthenia Gravis

A

Autoimmune disease - body attacks post synaptic nicotinic ACh receptors. Causes muscular weakness.

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8
Q

What drugs should be avoided or used with care in Myasthenia Gravis?

A

Paralytics.

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9
Q

What drugs are used to treat Myasthenia Gravis?

A

~ Pyridostigmine (anticholinesterase / cholinesterase inhibitor)
~ Corticosteroids
~ Immunosuppressives
~ With severe bulbar and respiratory compromise, IV Immunoglobulin (IVIG) or plasmapheresis preferred

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10
Q

Clinical manifestations of Myasthenia Gravis

A

Ocular
~ Diplopia
~ Ptosis
~ Ophthalmoplegia
Respiratory
~ Breathlessness
~ Weak Breathing
~ Respiratory Failure
Bulbar
~ Fatiguable chewing
~ Dysarthria
~ Dysphagia
Limbs, Neck
~ Dropped Head
~ Proximal > distal
~ Arms> legs

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11
Q

Myasthenia Gravis surgical treatment

A

Thymectomy: Removal of the thymus (thought to interfere with the production of autoantibodies) (tumor of thymus, called thymoma)

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12
Q

Myasthenia Gravis history exam:

A

clinical features of MG
disease severity
duration
medications
recent exacerbations

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13
Q

Myasthenia Gravis medecation recommendations

A

Pyridostigmine can be held if agreed upon by providers but is not recommended. Avoid premedication with sedatives or opioids because of CNS depressive effects.

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14
Q

Myasthenia Gravis Anesthesia Technique

A

Nerve blocks when possible. Caution in nerve blocks that could effect the phrenic nerve: diaphragmatic paralysis

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15
Q

Myasthenia Gravis steroids

A

If patients take long term steroids be aware a stress dose of steroid may be needed

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16
Q

Myasthenia Gravis, muscle relaxant approach

A

~ Depolarizing agents (succinylcholine) have unpredictable responses
~ Non-depoarizing agents are preferred with dose reduced by 1/3 to 1/2

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17
Q

Myasthenia Gravis other medications to avoid (NMB potential):

A

Certain antibiotic
Beta-blockers
Calcium Channel Blockers
Botox
Lithium
Magnesium
Verapamil

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18
Q

Myasthenia vs Cholinergic crisis!

A

Myasthenia crisis - exacerbation of disease - increased weakness and respiratory distress - treated with additional dose of NMB reversal

Cholinergic crisis: excess ACh at NMJ - increased weakness and respiratory distress, bronchospasm, sialorrhea, diarrhea, bronchorrhea

small dose of edrophonium to help distinguish one from the other

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19
Q

Cholinergic crisis (too much ACh)

A

Increased cholinergic activity
secretions increased
Bradycardia
Pupils constricted
Weak muscular tone and fasciculations
Edrophonium (Tensilon) test: Symptoms Exaggerated

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20
Q

Myasthenia Crisis (Not enough ACh)

A

Decreased cholinergic activity
secretions normal
tachycardia
pupils normal or dilated
weak muscular tone
Edrophonium (Tension) test: Relieves Symptoms

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21
Q

Leventhal criteria: Predictive scoring system for the need for postoperative ventilation in Myasthenia Gravis patients

A

1: Duration of disease for 6 years or longer
2: Chronic comorbid pulmonary disease
3: Pyridostigmine dose >750mg/d
4: VC <2.9L
5: Other indicators include preoperative use of steroids, and previous episode of respiratory failure

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22
Q

Myasthenia Gravis in neonates

A

~ Temporary due to transplacental transfer
~ Usually lasts a few weeks
~ Infants are floppy at birth, poor sucking, muscle tone, and respiratory effort
~ ICU obs with respiratory support and IV feedings
~ Short-term treatment with AChEIs possibly required
~ Infants of mothers who have taken corticosteroids should be monitored for adrenal inefficiencies during newborn period

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23
Q

Eaton-Lambert Syndrom is:

A

An auto immune disease in which antibodies are directed at voltage gated calcium channels in the presynaptic nerve terminals.

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24
Q

Eaton-Lambert Syndrom is most commonly associated with:

A

Small cell lung cancer

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25
Q

Eaton-Lambert Syndrom: muscle weakness is most significant when?

A

In the morning and improves as the day progresses

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26
Q

Eaton-Lambert Syndrom temperature considerations:

A

Avoid hypothermia as this may exacerbate condition

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27
Q

Myasthenia gravis vs Eaton-Lambert Syndrom (antibodies)

A

~ MG = Antibody against nAChR
~ LES = Antibody against voltage-gated Ca2+ channel

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28
Q

Myasthenia gravis vs Eaton-Lambert Syndrom (Tumor association)

A

MG = Associated with Thymic Tumor (Thymoma)
LES = Associated with Small cell lung cancer

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29
Q

Myasthenia gravis vs Eaton-Lambert Syndrom (Muscle weakness)

A

MG = Weakness worsens with prolonged exercise
LES = Weakness improves with prolonged exercise

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30
Q

Myasthenia gravis vs Eaton-Lambert Syndrom (DTRs)

A

MG = Normal DTRs
LES = Decreased or absent DTRs

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31
Q

Myasthenia gravis vs Eaton-Lambert Syndrom (Nerve stimulation)

A

MG = With repeated nerve stimulation, there is decremental response
LES = With repeated nerve stimulation, there is increased response

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32
Q

Eaton-Lambert Syndrom pre-anesthesia considerations

A

~ Evaluate lung function to assess post-op complication
~ PTs sensitive to depolarizing and non depolarizing NMB
~ Consider MAC or regional anesthesia if possible to avoid NMB

33
Q

Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig Disease) is:

A

A progressive incurable disease of degradation, dysfunction and eventual paralysis of upper and lower motor neurons

34
Q

Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig Disease) approximate survival time:

A

3-5 years after dx. Death results from ventilatory failure due to neuromuscular weakness

35
Q

Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig Disease) airway assessment

A

Possible masseter spasticity, muscular laxity leading to TMG dislocation

36
Q

Muscular Dystrophies: which is most common

A

Duchenne muscular dystrophy is most common with an occurrence of 1:3500 births

37
Q

What are Muscular Dystrophies:

A

X linked chromosome disease (can come from mom or dad). results for lack of dystrophin which helps anchor muscle cells to the extracellular matrix.

38
Q

Muscular Dystrophies: progression

A

Muscle fibers inadequately tethered, these fibers are then replaced with fibrous connective tissue leading to pseudohypertrophy (false enlargement from abnormal tissue, not muscle as in hypertrophy).

39
Q

Muscular Dystrophies: appear when

A

In childhood, with progressive wasting and weakness usually of the proximal muscles. Typically becomes fatal by late adolescent from respiratory or cardiac failure.

40
Q

Muscular Dystrophies: Becker’s muscular dystrophy mechanism

A

In Becker’s muscular dystrophy, the dystrophin protein is only partially absent. Symptoms are less severe.

41
Q

Muscular Dystrophies: Duchenne details

A

~ Most common type
~ Begins between ages 2 and 3
~ Affects lower limbs first
~ Impacts heart and respiratory muscles later on

42
Q

Muscular Dystrophies: Becker’s details

A

~ Appears between ages 5 and 15
~ Has slower progression than DMD
~ Affects hips and pelvic area first
~ Causes muscle weakness in the heart for most
~ Partial absence of dystrophin

43
Q

Muscular Dystrophies: Limb-Girdle details

A

~ Starts in either adulthood or childhood
~ Creates muscle weakness and atrophy in hips and shoulders
~ LGMD’s progression is dependent on the age of onset

44
Q

Muscular Dystrophies: Pre-Op considerations

A

~ Possible need for cardiology consultation due to presence of cardiac conduction abnormalities
~ Increased risk for preoperative complications including rhabdomyolysis, hyperkalemia, malignant hyperthermia, and cardiac arrest
~ Restrictive lung disease is present in DMD

45
Q

Guillain Barre Syndrome: what is it?

A

~ Immune-mediated polyneuropathy that often follows a viral or bacterial illness within the preceding 4+6 weeks

46
Q

Guillain Barre Syndrome: progression

A

~ Generally weakness ascending from the legs and is symmetrical
~ Rapidly progressing respiratory muscle weakness may result in intubation and ventilation

47
Q

Guillain Barre Syndrome: Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)

A

Most common for in North America and Europe. Most common sign is muscle weakness that starts in lower part of body and spreads upward

48
Q

Guillain Barre Syndrome: Miller Fisher syndrom (MFS)

A

Paralysis starts in the eyes. Also associated with unsteady gait. Less common in the U.S. but more common in Asia

49
Q

Guillain Barre Syndrome: Acute motor axonal neuropathy (AMAN) and Acute motor-sensory axonal neuropathy (AMSAN)

A

Less common in the U.S. but AMAN and AMSAN are more frequent in China, Japan, and Mexico

50
Q

Cerebral Palsy: what is it?

A

~ A group of chronic non-progressive disorders of motor development and posture
~ Caused by damage to a developing immature brain
~ Manifestation is variable
~ Aspiration due to bulbar muscle impairment and epilepsy are common

51
Q

Cerebral Palsy: Clinical Classification Spastic

A

Spastic (70%)
~ Quadriplegia (27%)
~ Diplegia - paralysis affecting symmetrical parts of the body (21%)
~Hemiplegia - partial or complete paralysis on one side of the body (21%)

52
Q

Cerebral Palsy: Ataxic

A

Ataxic (10%)
~ Intention tremor and head tremor, loss of balance

52
Q

Cerebral Palsy: Dyskinetic

A

Dyskinetic (10%)
~ Dystonia - involuntary muscle contractions that cause repetitive or twisting movements
~ Athetosis - slow involuntary and continuous writhing movements in the muscles of limbs, face, neck, tongue, and trunk
~ Chorea - movement disorder that causes involuntary, irregular, and unpredictable muscle movements

53
Q

Cerebral Palsy: Mixed

A

Mixed (10%)
~ Spasticity and athetoid movement

54
Q

Parkinsons Disease: What is it?

A

Without dopamine stimulation / inhibition from Substantia Nigra of the GABA sites in Striatum, unopposed Glutamate stimulation in Subthalamic Nucleus leads to GABA inhibition of Thalamic control of voluntary motor movement

55
Q

Parkinsons Disease: Classic Triad

A

Rigidity, Bradykinesia, Resting tremor

56
Q

Parkinsons Disease: Pharmacotherapy

A

Designed to restore dopaminergic acitivity in the dopamine-deplete striatum

57
Q

Parkinsons Disease: Carbidopa-levodopa

A

Carbidopa-levodopa (Sinemet) replaces dopamine

58
Q

Parkinsons Disease: Dopamine agonists

A

Dopamine agonists (pramipexole, lisuride, ropinirole) Stimulate dopaminergic receptors

59
Q

Parkinsons Disease: COMT inhibitors and MAO-B inhibitors

A

COMT inhibitors (entacapone, tolcapone, and opicapone) and MAO-B inhibitors (selegiline) inhibit dopamine metabolism

60
Q

Parkinsons Disease: NMDA inhibitors

A

NMDA inhibitors (amantadine) weak glutamate antagonist. Limits severity of levodopa-induced dyskinesias

61
Q

Parkinsons Disease: Deep brain stimulation

A

Deep Brain Stimulation (DBS) of sub thalamic nucleus is effective for all major movement symptoms of Parkinson’s disease (tremor, bradykinesia, rigidity, and problems with walking and balance)

62
Q

Parkinsons Disease: specific patient med history

A

Obtain detailed medication history and exact dosing schedule. Have pt bring home anti-PD meds as they may not be formulary (to avoid missed doses and abrupt interruption)

63
Q

Parkinsons Disease: surgery timing

A

Schedule surgery early in the morning to minimize missed / delayed doses of anti-PD meds, preserve sleep-wake cycle, and resume mobility on DOS whenever possible

64
Q

Parkinsons Disease: MRI

A

Asssess MRI safety of deep brain stimulator ahead of time incase MRI is needed

65
Q

Parkinsons Disease: morning of medecations

A

Have patients take morning anti-PD medications morning of surgery unless contraindicated (Levodopa may be given 20-30 min prior to induction and resumed post-op in the PACU as soon as the patient is awake).

66
Q

Parkinsons Disease: prolonged fasting and orthostatic hypotension

A

Plan surgery to minimize fasting while still considering risk of aspiration

67
Q

Parkinsons Disease: MAOIs and inhibition of phenylpiperidine narcotic metabolism

A

Avoid meperidine, fentanyl, indirect-acting sympathomimetics

68
Q

Parkinsons Disease: Worsening of extrapyramidal effects

A

Avoid dopaminergic antagonists (haloperidol, droperidol, metoclopramide come to mind)

69
Q

Parkinsons Disease: pre-existing DBS may be damaged with electrocautery use

A

Turn off DBS prior to surgery if electrocautery to be used. Request bipolar cautery

70
Q

Parkinsons Disease: Increased risk post-op pulmonary complications

A

Preoperative spirometry training. Coordination with physical therapy / Rehab services

71
Q

Seizures: mode of presentation for

A

intracranial tumors

72
Q

Seizures: Medications in the perioperative period

A

Continue anti epileptic medications throughout the perioperative period.
~ One exception: patients requiring intraoperative electroencephalography (EEG) monitoring and localization

73
Q

Seizures: Antiepileptic drugs Mechanism of Action

A

Inhibit depolarization of neurons by:
~ Inhibition of excitatory neurotransmission (Glutamate)
~ Enhancement of inhibitory neurotransmission (GABA)
~ Blockage of voltage-gated positive current (Na+) and (Ca2+) channels
~ Increase outward positive current (k+)
***Most alos induce hepatic enzymes altering the pharmacokinetics of your anesthetic agents (don’t last as long)

74
Q

Seizures: History

A

frequency of seizure, type, last seizure occurrence, postictal phase, history of status epileptics, home anti seizure medications regimen and any adverse effects, compliance with antiseizure medications

75
Q

Seizures: Labs

A

Obtain CBC and CMP blood levels of anti-seizure medications not required unless concerned about toxicity or non-adherence (surgery and anesthesia can significantly alter serum levels of anti seizure medications)

76
Q

Seizures: medications prior to surgery

A

~ Morning of surgery, allow P.O. anti seizure meds with small sips of water
~ If patient is strict NPO or having intestinal surgery: give parenteral formulation of anti-seizure medication

77
Q

Seizures: and pregnancy

A

Assess pregnancy status in women of child-bearing age to guide the choice of anti-seizure medication. Keppra probably the safest

78
Q

Good things to remember:

A

~ The major cause of death in patients with NM disorders is respiratory insufficiency
~ extent of general muscle weakness does not necessarily correlate with the severity of respiratory muscle involvement
~ Cardiovascular involvement may manifest as autonomic dysfunction in patients with neuropathic disorders
~ Clinical signs of autonomic dysfunction include: orthostatic hypotension and resting tachycardia
~ Presence of these clinical signs may indicate profound hemodynamic instability requiring invasive monitoring to manage intravascular volume status and myocardial contractility
~ Severity of skeletal muscle involvement does not necessarily correlate with severity of cardiac involvement

Assessment 2 (3 decks)

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