Special Populations Exam 1-S5 Flashcards
Which type of muscle is not under conscious control and is found within walls of organs and structures such as?
- esophagus
- stomach
-intestines
- bronchi
- uterus
- blood vessels
Smooth muscle
Which type of muscle contain sarcomeres and packed into highly regular repeating arrangements of bundles?
- Striated
Cardiac and Skeletal muscle
Cardiac muscles connects at branching, irregular angles called ___ ___?
Intercalated discs
In the neuromuscular junction which area contains acetylcholinesterase (AChAse)?
Synaptic cleft
Nerve stimulation is caused by depolarization and voltage gated ____ channels open?
Calcium
ACh diffuses across the synaptic cleft and binds to the _____ receptor postsynaptically?
nicotinic cholinergic
Only 2 ____ subunits are capable of binding ACh
Alpha
With depolarization Action potential, ____ and ____ move IN ?
Sodium and Calcium
With depolarization Action potential, ____ moves OUT?
Potassium
The amount of ACh released is influenced by the amount of ___?
Calcium that enters the nerve terminal
Small concentrations of what 2 cations can compete with Calcium influx and can decrease the ACh release and impair neuromuscular transmission?
Magnesium
Aminoglycoside antibiotics
When the frequency of stimulation of NMJ decreases over days to severe burns, immobilization, infection, sepsis and prolonged use of NMBA can cause what?
UPregulation of receptors
Chronic neostigmine use can lead to what?
- Too much ACh
DOWNregulation of receptors
This condition is characterized by inflammation, demyelination, immune dysfunction and failure of cell repair in the CNS?
- muscle weakness
- memory loss
- optic neuritits
- personality disorders
- 8x higher in females
- chronic relapses and remissions
- peripheral nerves not affected
Multiple sclerosis
This condition is an autoimmune disease characterized by T-cell mediated autoantibodies against myelin?
Multiple sclerosis
This condition symptoms begin
20-40 years of age and have 2 or more attacks separated by a month, involve 2 or more areas and elevated IgG and albumin in the CSF?
Multiple sclerosis
How is multiple sclerosis affected by pregnancy?
Reduced risk of exacerbations while pregnant, but increased risk of relapse in postpartum
Treatment for Multiple Sclerosis includes which medications?
Interferon beta- disease modifying agent
Azathioprine, corticosteroids and IV immunoglobins for immunosuppression
Gabapentin for neuropathic pain
Lhermitte sign on assessment is associated with what disease?
Multiple sclerosis
Neck flexion induced electrical sensation
Unthoff sign on assessment is associated with what disease?
Multple sclerosis
Increased body temp/hot flashes
Anesthetic implications of Multiple sclerosis include what?
symptoms of hyperthermia
- Avoid succinycholine due to hyperkalemia
- spinal anesthesia may exacerbate symptoms
Which condition is caused by Amyloid beta protein that creates amyloid plaques, neurofibrillary tangles, and neuronal apoptosis?
- Loss of cholinergic activity
Alzheimer disease
Treatment of Alzheimer disease include the use of which medications?
Acetycholinesterase inhibitors
- Glycopyrrolate due to quat
Which condition is caused by loss of dopaminergic cells in the basal ganglia (lewy bodies)?
Parkinson Disease
Which condition is associated with resting tremor, bradykinesia, shuffling gait, facial immobility and diminished inhibition of extrapyramidal motor system?
Parkinson Disease
Treatment for Parkinson disease?
Levodopa
- do not stop medication for more than 6 hours (muscle rigidity, ventilation issues)
Which 2 medications should you not given to patients with parkinsons?
Reglan and Phenergan (dopamine antagonists)
Increased risk of neuroleptic syndrome
Deep brain stimulator would be most beneficial for which type of patients?
Parkinsons patients due to treatment of severe tremors
Which cerebral cortex motor neurons are affected with ALS?
Upper, Lower, or Mixed
Mixed
Which cerebral cortex motor neurons are affected with Kennedy’s disease?
Upper, Lower, or Mixed
Spinobulbar muscular atrophy
Which cerebral cortex motor neurons are affected with Friedreich’s ataxia?
Upper, Lower, or Mixed
Mixed
Which cerebral cortex motor neurons are affected with Spinal muscular atrophy?
Upper, Lower, or Mixed
Lower
Which condition is this?
- males affected more
- onset 40-60 years
- selective and progressive motor neuronal death
- no treatment
- should avoid general anesthesia and avoid succinycholine
- avoid opioids and benzos due to resp depression
ALS
amytrophic lateral sclerosis
This condition is caused by a sodium channel defect causing prolonged depolarization and flaccid paralysis?
- muscle weakness to tongue and eyelids
- precipitated by metabolic acidosis and cold exposure
- avoid succinycholine
Hyperkalemic periodic paralysis
K >5.5
This condition is caused by calcium or sodium channel defect
- chronic myopathy with aging
- precipitated by stress, hypothermia, high glucose meal
- sensitive to nondepolarizing NMBA
Hypokalemic periodic paralysis
K < 3
This condition is an autoimmune disorder characterized by onset of ascending skeletal muscle weakness/paralysis of the legs due to viral or bacterial infection?
- autonomic dysfunction fluctuations in HR and BP
- cardiac dysrhythmias
- weak respiratory muscles
Guillain-Barre syndrome
Treatment for Guillain-Barre syndrome includes?
Plasma exchange, immunoglobulin
Anesthetic considerations of Guillain-Barre syndrome include?
Avoid rapid movement of patient
Maintain temperature
Monitor for respiratory failure
Avoid succinycholine
Which condition is caused by a decrease in the number of functional postsynaptic, acetylcholine receptors in the neuromuscular junction available for acetylcholine binding?
Myasthenia Gravis
Fatigability/muscle weakness that improves with rest is the hallmark sign of what?
Myasthenia Gravis
What is the protein that allows AChR to cluster at the NMJ?
Muscle Specific Kinase (MuSK)
What is the major antigen in Myasthenia Gravis?
Acetylcholine receptor (AChR)
What is the first notable sign of Myasthenia Gravis?
Weakness of extraocular muscles, diplopia
In Myasthenia Gravis, patients with thymomas can develop what?
Myocarditis
The Tensilon test in diagnosing Myasthenia Gravis is done using which medication?
Edrophonium
Improvement in strength = positive
What represents the most common anterior mediastinal mass shift in patients with Myasthenia Gravis?
Thymus hyperplasia
This condition is characterized by progression to severe muscle weakness, respiratory failure, bundle branch blocks and AFIB?
Myasthenia Crisis
Pregnancy exacerbates the symptoms of ____ by 33%?
- most often in 1st trimester or 6 weeks postpartum
Myasthenia Gravis
The newborn of a mother with Myasthenia Gravis can suffer from ____ which presents as difficulty feeding, ptosis, facial weakness, and respiratory distress 12-48hrs after birth?
Transient Neonatal Myasthenia
lasts for weeks
Difficulty swallowing
Slurring of speech
Difficulty breathing
Neck muscle weakness
are all known as what?
Bulbar symptoms
What is the treatment of Myasthenia Gravis?
Oral Pyridostigmine
- quaternary, does not cross BBB
- improves muscle strength for several hours
- increases conc of ACh at postsynaptic membrane
Diarrhea, urination, miosis, bradycardia, emesis, lacrimation, lethargy and salivation are symptoms of what condition?
Cholinergic Crisis
A thymectomy can be beneficial for treatment of which disease?
Myasthenia Gravis
Discussion for possibility of postoperative ventilation is needed for which type of patients?
Myasthenia Gravis
Forced vital capacity < 2.7L
Vital capacity < 4ml/kg
History of myasthenia crisis
Disease duration > 6 years
Daily Pyridostigmine 750mg or more
COPD
Bulbar symptoms
all what???
Factors that anticipate postoperative mechanical ventilation
Which condition does exercise improve the muscle weakness-related symptoms?
Lambert-Eaton Myasthenic syndrome
What condition is an autoimmune disorder associated with paraneoplastic small cell lung cancer, IgG antibodies attack pre-synpatic calcium channels?
- Decreased release of ACh from presynaptic terminals
- No ocular involvement
- No improvement with ancticholinesterase
Lambert-Eaton Myasthenic Syndrome
What condition is an X-linked recessive disease in which the muscles are replaced with fat/tissue?
- Presents in childhood (3-5)
- Caused by the loss of functional Dystrophin
- Proximal muscle weakness and gait issues (Gower’s Sign)
- elevated CK levels
Duschenne’s Muscular Dystrophy
Which protein plays a major role in stabilization of the muscle membrane and signaling cytoskeleton and extracellular matrix?
- Loss of this protein causes DMD
Dystrophin
Patients with Duchenne’s Muscular dystrophy are especially sensitive to what medications?
Cardiac depressants
Avoid inhalational, sedatives and narcotics
Which medication is an absolute contraindication to Duchenne muscular dystrophy?
Succinycholine
Hyperkalemia
Rhabdomyolysis
Which condition is caused by decreased in normal amounts of dystrophin. Milder than DMD and onset is around 12 years old?
Becker Muscular Dystrophy
Which condition is caused by mutations in 2 proteins that presents with contractures of the ankles, elbows and neck?
- progressive weakness of humeral and peroneal muscles
- Cardiomyopathy and conduction abnormalities
Emergy-Dreifuss Muscular Dystrophy
These symptoms are common to all what?
- Inability of skeletal muscles to relax after stimulation
- Dysfunction of ion channels
- Reduced conductance of chloride ions
- Progressive muscle wasting with weakness
Myotonia
Which condition is an autosomal dominant disorder that has a slow, progressive deterioration of skeletal, cardiac, and smooth muscle wasting?
- Characterized by hypoplastic, dystrophic and weak skeletal muscles and prone to persistent contraction
2 types
Myotonic Dystrophy
Which type of Myotonic Dystrophy?
- Congenital, childhood onset, adult onset
- Most common type
- Myotonic-protein kinase gene
- Defect in Na and Cl channel function
- Conduction defects, heart blocks
- muscle weakness begins distally
- MR, frontal baldness, and cataracts
- Diabetes
DM-1 Steinerts
Which type of Myotonic Dystrophy?
- Proximal myotonic myopathy and myopathy
- Less likely to have Diabetes
- Normal life expectancy
DM-2
Which condition is associated with Sudden cardiac death related to 3rd degree block, respiratory failure or pneumonia?
DM-1
Myotonic Dystrophy
Anesthetic considerations for Myotonic Dystrophy I and II patients?
Have pacer avaliable due to conduction defects
CAN use inhalational agents
NO greater risk of MH
Which condition is an autosomal dominant disorder linked to RYR1 ryanodine receptor on the Sarcoplasmic Reticulum mutation resulting in a massive release of intracellular calcium within skeletal muscle?
Malignant Hyperthermia
Triggering agents for Malignant Hyperthermia include?
Volatile agents
Succinycholine
Early signs of MH include?
Hypercarbia, Rapid increase in etCO2
Masseter muscle rigidity
Tachycardia
Late signs of MH include?
Hyperthermia
Acidosis
Rhabdomyolysis
What to do before case with a patient who has a history of MH?
Flush the anesthesia machine
TIVA
Have MH cart avaliable
Activated charcoal filters on expiratory and inspiratory limb
What condition is associated with an Antipsychotic induced Dopamine blockade leading to sudden drop in CNS activity?
- Muscle rigidity (1st sign)
- Impaired heat regulation (fever)
- AMS
- Labile BP, tachypnea
Neuroleptic Malignant Syndrome
Treatment for Neuroleptic Malignant Syndrome?
Stop offending agent
Give benzos or Dantrolene
Which condition is associated with enzymatic deficiencies in the heme synthesis pathway?
- Accumulation of neurotoxic precursors (PBG) and (ALA)?
- 1st line screening test is urinary prophobilinogen (PBG) elevation?
Porphyria
Which condition is triggered by hormone changes during menstrual cycle, fasting, infection and exposure to barbituates/etomidate?
- unexpected delayed emergence from anesthesia
- fever, tachycardia, N/V, abdominal pain, weakness, hyponatremia, resp failure?
Acute Intermittent Porphyria
(AIP)
Prolonged apnea after succinycholine and 0/4 twitches minutes later can be caused by what?
Plasma cholinesterase disorder
Dibucaine number 70-80?
Homozygous Typical
Normal response
Dibucaine number 50-60?
Heterozygous Atypical
Lengthened 50-100%
Dibucaine number 20-30?
Homozygous Atypical
Prolonged 4-8 hours
What connects the anterior carotid and posterior vertebrobasilar circulation as the major intracranial arterial system?
- Collateral blood flow
Circle of Willis
Venous drainage of the brain happens where?
Internal Jugular Veins
The cerebral ventricular system is made up of 4 ventricles. The third ventricle is located where?
Diencephalon
The cerebral ventricular system is made up of 4 ventricles. The fourth ventricle is located where?
Hindbrain
Where is CSF produced?
Choroid Plexus of the lateral, third and fourth ventricles
How much CSF is produced every day?
How much CSF is in circulation at any given time?
400-600ml
150ml
Where is CSF reabsorbed?
Arachnoid Villa
Where does the spinal cord begin?
Foramen magnum
continuation of the Medulla Oblongata
How many segments does the spinal cord divide into?
31 segments
Cervical-8
Thoracic-12
Lumbar-5
Sacral-5
Coccygeal-1
Somatic motor neurons travel in the ____ motor columns that innervate the upper and lower limbs?
Medial
What are the major ascending tracts in the body?
Dorsal column- proprioception
Spinothalamic tract- pain, temp
What is the major descending tract in the body?
Corticospinal tract
Controls fine movement
What supplies blood to the anterior two-thirds of the spinal cord and medulla?
Anterior spinal artery
What supplies blood to the lower two-thirds of the posterior spinal cord?
Artery of Adamkiewicz
T9-T12 start
What supplies blood to the posterior one-third of the spinal cord?
2 Posterior spinal arteries
What is the main substance the brain uses for energy production?
Glucose
What % of cardiac output does the brain receive?
15%
Cerebral perfusion pressure calculation?
CPP= MAP-ICP
Normal ICP?
7-15 mmHg
At what ICP does redistribution of CSF happen?
Above 20 mmHG
At what ICP does vascular structures collapse?
40-50 mmHG
At what ICP is there a high risk for herniation?
Over 50 mmHG
Symptoms of Cushing’s Triad include what 3 things?
Reflects severe increased ICP
Hypertension
Bradycardia
Irregular respirations
What protects the brain from hypo/hyperperfusion secondary to decrease/increase in CPP?
Cerebral autoregulation
When it comes to Cerebral blood flow, an increase in PaCO2 will result in what?
1 mmHg increase in PaC02 results in 1-2 ml/min increase in CBF
Which neuromonitoring monitor the sensory pathway through the dorsal root ganglia and posterior column?
- Sensitive to inhalational agents and nitrous
SSEP
Which 2 IV drugs increase SSEP amplitude?
Ketamine and Etomidate
Which neuromonitoring monitor the motor pathway including the motor cortex, corticospinal tract and peripheral nerve by transcranial stimulation?
- More sensitive to the effects of anesthetic agents
- Signals weakened or eliminated by NMBA
MEPs
Which neuromonitoring monitor cortical electrical activity with scalp electrodes to detect cortical ischemia or seizure activity?
- Can also monitor depth of anesthesia
- dose dependent affects with anesthetics
EEG
Which neuromonitoring monitor nerve roots and peripheral nerves by detecting muscle activity or nerve action potentials?
- Continuous monitoring and detection of neuronal structures during surgical dissection of nerve roots
- can be used to assess pedicle breach during screw placement
- ONLY affected by NMBA, not anesthetics
EMG
Which neuromonitoring monitor the auditory nerve and auditory pathway through brainstem acoustic stimulation?
- used during skull base surgery
- affected by Hypothermia
BAEPs
Which medications have increased latency and decreased amplitude on SSEP monitoring?
Propofol
high dose barbituates
Which medications have increased amplitude on SSEP monitoring
Ketamine and Etomidate
Which medications have increased latency and decreased amplitude on MEP?
Propofol, high dose barbituates
precedex
lidocaine
How do volatile anesthetics affect CBF and Cerebral metabolic rate of oxygen?
Dose dependent reduction in CMR02 and Increase in CBF
Which agent results in an increased CBF and increased CMR02?
Nitrous Oxide
How does propofol affect the brain?
Reduced CMR and CBF
How does Etomidate affect the brain?
Reduced CMR and CBF
Increased alpha wave amplitude on EEG
How does Ketamine affect the brain?
Increases CMR and CBF
does NOT lower seizure threshold
Increases amplitude of SSEPs
How do benzos affect the brain?
Reduced CMR and CBF
May reduce ICP
How do Opioids affect the brain?
Not really any affect on CMR or CBF
How do NMBA affect the brain?
Mild increase in ICP with succinycholine
At what GCS would you intubate the patient?
< 8, intubate
Where is the A-line leveled to approximate the circle of Willis?
External auditory meatus
What surgical position is associated with these effects?
- HR and SVR lower
- upward displacement of diaphragm
- decreased FRC
- lung perfusion increased
- pregnant at increased for aortocaval compression
Supine
What surgical position is associated with these effects?
- Pooling of blood in dependent extremity
- Decreased venous return
- V/Q mismatch
- possible hypoxia
Lateral
What surgical position is associated with these effects?
- Decreased CO due to decreased venous return
- improved FRC if not obese
- increased intrathoracic pressure
Prone
What surgical position is associated with these effects?
- Hypotension from decreased venous return
- cerebral hypoperfusion risk
-FRC increased
- Venous air embolism potential complication
Beach chair/seated
Solutions containing ____ are avoided in all neurosurgical patients due to ischemic damage and cerebral edema?
Glucose
What are 3 ways to cause cerebral vasoconstriction to decrease ICP?
Hyperventilation
Head elevation to increase drain
Keep MAC < 0.5 to avoid vasodilation
Which drug pulls water across the blood brain barrier to restore osmolar balance?
- “brain epi”
- Caution use with CHF patients
Mannitol
Which drug reduces ICP by inducing a systemic diuresis and decreases CSF production?
Furosemide
What is typical symptom of a venous air embolism?
Most sensitive for diagnosis?
Mill-wheel murmur
TEE most sensitive
What manuever for treatment of venous air embolism?
Durant’s maneuver
Left side down
Eloquent cortex surgery is typically done by what procedure?
Awake Craniotomy
What condition is most common in complete C-spine transection?
- hypotension
- bradycardia
- hypothermia
- injury above T6 level
- lose of vascular tone
Neurogenic shock
A drug with a high VD value indicates what?
Drug is distributed more in tissue than in plasma
What is described as a 50% decrease in plasma concentration after stopping IV infusion?
Context sensitive half time
Which receptors are decreased in the elderly population?
B- receptors
In the elderly population, there is stiffening of the heart ventricles, slowing of diastolic relaxation, impaired ventricular filling and diastolic dysfunction which lead to what?
Hypertrophy
The loss of SA node cell automaticity leads to what syndrome?
- need for pacemaker
Sick sinus syndrome
Need for pacemaker
Increased risk of MI
Surgical wound infection
Coagulopathy
Impaired drug metabolism
All are associated with what in the elderly population?
Hypothermia
What are the 3 most common medications that cause postoperative delirium in elderly population?
Atropine
Opioids
Benzodiazepines
Burst suppression is high risk for delirium?
T/F
True
Which obesity type?
- body fat in the upper body (truncal)
- very metabolically active
- increased O2 consumption
- higher rate of CV disease
- Most dangerous
Android
Which obesity type?
- fat mostly located in the hips, buttocks and thighs
- less metabolically active
- less associated with CV disease
Gynecoid
BMI of
18.5-24.9
Normal
BMI of
25-29.9
Overweight
BMI of
30-34.9
Obesity Class 1
BMI of
35-39.9
Obesity Class 2
BMI of
40-49.9
Morbid obesity
BMI of
50-59.9
Super morbid obesity
BMI of
>60
Super super morbid obesity
What is the most commonly reported pulmonary abnormality to obesity?
Decreased FRC and ERV
What is the most sensitive indicator of obesity effects on the body?
End reserve volume
OSA classification( # of apnea events/hr)
Normal?
Mild?
Moderate?
Severe?
Normal- < 5
Mild- 5-15
Moderate 15-30
Severe > 30
Alveolar hypoventilation independent of intrinsic lung disease is associated with what syndrome?
Obese hypoventilation syndrome
Pickwickian
What are the 2 most sensitive EKG monitors for ischemic events?
II and V5
Abdominal obesity, glucose intolerance, HTN, dyslipidemia and increased vascular events are related to _____ _____?
Metabolic syndrome
“Bull’s eye” on POCUS view is indicative of what?
Empty antrum- Good
“Starry night” on POCUS view is indicative of what?
Clear fluid with air
“Frosted glass” on POCUS view is indicative of what?
Solid food contents with air
What is the most effective bariatric surgery for treatment of obesity that can produce 50% weight loss in patients?
Roux-en-Y Gastric Bypass
If patient is receiving Heparin 5000u or Unfractionated Heparin 40mg how long should wait for epidural?
> 12 hours
What is the #1 indicator of problematic intubation in obese patients?
Neck circumference
> 40cm
What is the greatest at risk of developing SIDS in between how old?
1 month and 1 year
How long to wait for clear liquids?
2 hours
How long to wait for breast milk?
4 hours
How long to wait for infant formula?
6 hours
How long to wait for heavy meal?
8 hours
3x 250mg vials of Ryanodex kept on hand
36 vials of Dantrolene kept on hand
Ryanodex -750mg
Dantrolene 720mg
How long should patient be monitored in PACU non-OSA?
3 hours
How long should patient be monitored in PACU WITH OSA?
7 hours
Administration of what type of drugs can induce skeletal muscle rigidity and chest wall rigidity?
Opioids
What is the most common clinical sign of myocardial ischemia?
Tachycardia
What is the most common cause of delayed awakening?
Prolonged action of anesthesia
The #1 cause of hypothermia in the OR is due to what?
Radiation
