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NU 758 Adv Principles > spine/thyroid/obesity > Flashcards

spine/thyroid/obesity Flashcards

1
Q

2 most common reason for spine sx

A

disc herniation and spinal stenosis

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2
Q

whats the biggest anesthetic challenge for spine cases

A

positioning: use of prone, supine, lateral , or a combination

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3
Q

5 challenges for spine cases

A
  1. positioning
  2. high blood loss
  3. use of IONM and impact on anesthetic plan
  4. the need for multimodal pain mgmt
  5. often in elderly or peds with other comorbidities
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4
Q

why should the head be kept in a neutral position in spinal cases? (name degree and location of compromise)

A

60 degree rotation = restricted contralateral vertebral artery flow
80 degree rotation = occluded contralateral vertebral artery flow

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5
Q

concerns with the use of the wilson frame (3)

A
  1. head is lower than the heart making BP monitoring challenging
  2. RF for POVL
  3. risk for VAE
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6
Q

what are the 2 main types of POVL

A

-CRAO: central retinal vascular occlusion (compression)
-ION: ischemic optic neuropathy (hypoperfusion)

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7
Q

7 RF for POVL

A
  1. male
  2. obesity
  3. wilson frame
  4. long sx time (>6h)
  5. hypotension
  6. Prone spine cases (also high risk with cardiac cases)
  7. high EBL
    (8. some sources say use of colloids but others advocate for it)
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8
Q

presentation of POVL

A

painless, bilateral vision loss. loss of light perception. decrease or loss of color perception. non-reactive pupils. occus 24-48h post-op

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9
Q

most important goal of ERAS for spine

A

return to baseline functional capacity

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10
Q

4 risks/complications assoc with ACDF

A
  1. nerve injury
  2. vessel injury
  3. esophageal injury
  4. PTX
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11
Q

considerations for ACDF induction and most common type of anesthesia

A

-careful airway exam…assess c-spine mobility and assoc symptoms
-prob will need VL

-GA+ ETT

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12
Q

can you use inhalationals with ACDF and SSEP monitoring

A

<1 MAC with SSEP

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13
Q

what 2 drugs are contraindicated with MEP

A

Mag
NeuroMuscular blockers
(MEP: MMNM)
also avoid inhalationals

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14
Q

emergence considerations for ACDF (4)

A

-extubate awake to check neuro function (must assess neuro function before leaving the OR)
-avoid coughing and bucking due to risk for hematoma which requires immediate sx evacuation
-assess for RLN injury (know uni/bi lat presentation)
-may require a brace per surgeon

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15
Q

what is the leading cause of work absences and what is the most common site of injury

A

back injuries, L4/5 or L5/S1

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16
Q

what type of anesthesia is contraindicated with IONM

A

regional (both spinal and epidural bc they interrupt both sensory and motor function)

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17
Q

what should you always do after changing pt position

A

reassess ETT placement

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18
Q

what does sudden profound hypotension suggest during spine sx

A

major vessel injury

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19
Q

in prone, whats the max ml/kg of crystalloid to give and why

A

40ml/kg, risk of ION POVL if more

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20
Q

above what level do you need a DL ETT to collapse the lung on operative side for thoracic spine surgery

A

T8

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21
Q

what is a risk with thoracic fusions

A

Spinal cord injury

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22
Q

what is a risk with thoracoabdominal approach for spinal sx

A

respiratory compromise
(may also require rib removal)

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23
Q

what is the most frequent non-traumatic cause of SC transection

A

MS

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24
Q

what level SC transection is incompatible with life unless intubated

A

C2-4

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25
Q

where is temp regulation lost in the setting of SCI

A

BELOW the level of injury

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26
Q

do you still need to anesthetize patients with autonomic hyperreflexia/loss of innervation

A

YES: they still have hyperactive ANS. anesthesia attenuates the ANS and hyperactivity to avoid HTN and low HR

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27
Q

at what level are you concerned about autonomic hyperreflexia

A

above T6

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28
Q

s/s of autonominc hyperreflexia

A

severe HTN and bradycardia
(HA, pallor, cool, sweating)

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29
Q

when is scoli sx indicated regarding the Cobb angle

A

> 40-50 degrees or rapidly progressing

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30
Q

what lung pathology is seen with scoli patients

A

restrictive lung disease

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31
Q

implication of PFTs and scoli sx? if VC is…

A

<40% of predicted, keep intubated post-op

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32
Q

POVL is characterized by:

A

loss of pupil rxn and occurs 24-48h post-op
(Kahoot answer)

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33
Q

leading cause of death in chronic SCI patients

A

renal injury

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34
Q

most appropriate type (not agent) of anesthetic for IONM

A

GA (you cannot use regional)

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35
Q

effect etomidate has on IOMN

A

increases amp and increases latency

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36
Q

what agents decrease amplitude and increase latency

A

N2O, sevo, brevital (from kahoot)

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37
Q

where is the thyroid gland located

A

-anterior to the trachea
-caudad to the hyoid bone, cricoid cart, and thyroid cart
-cephalad to the suprasternal notch

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38
Q

what supplies blood to the thyroid gland

A

superior and inferior thyroid arteries provide an extensive blood supply

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39
Q

what nerve borders the thyroid gland b/l

A

RLN

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40
Q

what are the functional units of the thyroid gland and what do they do

A

-follicles (surrounded by epithelial cells, center is made of a colloid called thyroglobulin)
-make and store thyroid hormones (controlled by TSH)
–tyrosine and iodine are needed to make

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41
Q

what is the rate limiting step of thyroid synthesis

A

iodine trapping

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42
Q

where is TSH released from

A

anterior pituitary

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43
Q

describe T3 and T4

A

T3: active/less bound, potent form, only 7% of released thyroid hormone, t1/2 = 24h

T4: bound, less active/potent form. gets deiodinated to T3. T1/2 = 6-7d

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44
Q

what feedback loop does T4 have

A

Negative (on the hypothalamus and ant pit)

hypothal –> TRH –> ant pit –> TSH –> thyroid –> T3/4

45
Q

relationship of calcium and phosphorus

A

inverse

46
Q

effect of alkalosis on ical

A

alk shifts ical into PB and REDUCES serum levels
high pH = low ical

47
Q

effect of acidosis on ical

A

acidosis release PB of ical

low pH = high ical

48
Q

what does calcitonin do

A

lowers ical
(opposite effect of PTH…inhibits osteoclasts)

49
Q

what type of aneshesia is most common for thyroid/pth surgery? what NMB would you use?

A

GA with std induction/maint
succ bc of short DOA (cannot use paralytics with NIM ETT)

inhaled and TIVA can be used, but TIVA is most common per Cassie

50
Q

What does the NIM ETT tube do

A

monitors VC and RLN function

51
Q

2 drugs to avoid with NIM ETT

A

paralytics and lido (tracheal/laryngeal application)

52
Q

3 complications of thyroidectomy

A
  1. RLN injury
  2. hypoPTH/hypocal (intentional or accidental removal of PTH)
  3. hematoma
53
Q

unilat vs bilat RLN injury post thyroidectomy

A

uni (ipsilateral VC remains midline)= hoarseness that usually improves

bilat = aphonia, stridor, airway obstruction…emergency

54
Q

signs of hypocal and treatment

A

long QT, hypotension, laryngospasm/stridor, myocardial depression, tingling in lips/fingers, tetany, seizures, muscle spasms, hyperactive DTR, +chvostek & trousseau sign
Treat: give cal chl or cal glu

55
Q

why is a hematoma post thyroidectomy concerning and what is the treatment?
how can we help avoid this?

A

-airway obstruction
-surgical evacuation
-avoid coughing/bucking on emergence (use remifent)

56
Q

s/s of hypercalcemia and treatment

A

HTN, short QT, conduction disturbance, confusion/lethargy, bone pain, osteopenia/fractures, anorexia, n/v, pancreaatitis, polyuria, polydipsia, kidney stones

-give isotonic IVF (not LR) to dilute it, loop diuretics to excrete it
-monitor ECG & renal function

57
Q

CV differences for hypo/hypercal

A

hypo: long QT, hypoTN, myocardial depression

hyper: short QT, HTN, conduction disturbances

58
Q

what labs are monitored intra and post op parathyroidectomy

A

calcium and PTH levels
(mag and phos may also be monitored)

59
Q

when do calcium levels drop post-parathyroidectomy? what do you need to watch for?

A

immediatey
-neuromuscular excitability –> laryngospasm

60
Q

should patient continue thyroid meds peri-op?

A

yes- the goal is for patient to be euthyroid

61
Q

s/s of hypothyroid (15 from cassies slide)

A

goiter, slow metabolism, cold intolerance, fatigue, depression, joint & muscle pain, dry/brittle hair and skin, puffy face
CV: labile BP, arrhythmia, cradiomegaly, poor contractility, abnormal baroreceptor function, HF

62
Q

primary vs secondary hypothyroid

A

primary = high TSH, low T3/T4
secondary = low TSH, low T3/T4

63
Q

is ventilatory reponse to hypoxia and hypercarbia impaired with hypothyroid?

A

yes

64
Q

3 possible airway concerns with hypothyroid

A

goiter, enlarged tongue, tracheal deviation/compression

-pre-op imaging may be needed, consider FIB intubation

65
Q

anes for hypothy (box 37.13)
1. euthyroid? y/n
2. should you assess for goiter? y/n
3. continue meds day of?
4. effect of anes on CNS
5. hepatic/renal effects & dosing?
6. will pt be warm or cool?
7. effect of NMBs?
8. blunted ventiatory response?
9. CV effect?
10. increase or decerae in plasma volume when calculating fluid replacement?

A
  1. yes
  2. yes
  3. yes
  4. exaggerated CNS depression
  5. may decrease dose due to impaired metabolism
  6. cool. use warming devices
  7. may be profound if existing weakness
  8. yes
  9. depressed
  10. reduction
66
Q

myxedema coma
-4 hypo…
-plan?

A

-severe hypothyroid
-hypoBP, hypoventilation, hypothermia, hypoNa
-intubate (usually) and delay surgery

67
Q

biggest cause of hyperthyroidism

A

graves disease

68
Q

4 RF for hyperthyroidism

A

female, genetics, stress, cigarette smoking

69
Q

what drug can affect thyroid levels

A

amio (hyper or hypo)

70
Q

primary hyperthyroid vs subclinical hyperthyroid

A

primary = low TSH, high T3/4

subclinical = Low TSH & T3/4

71
Q

s/s hyperthyroidism

A

hypermetabolic stte, tachycardia, wam/moist skin, tremor, diarrhea, osteopenia, muscle weakness, wt loss, anxiety, heat intolerance, ocular abnormaliteies

72
Q

3 RF for thyroid cancer

A

female, radiation exposure, inherited syndromes

73
Q

3 anesthetic choices for thyroidectomy

A
  1. GETA (most common)
  2. LMA
  3. local & sedation with b/l cervical plexus blocks
74
Q

what might be the best option for intubation for throidectomy

A

awake fiberoptic intubation

75
Q

what drugs to avoid with thyroidectomy (for hyperthyroidism)

A

drugs that stimulate the SNS: ketamine, glyco, vagolytics, panc

76
Q

should you use direct or indirect acting vasopressors with thyroidectomy

A

direct bc if high catecholamines at baseline, indirects will release more and can cause CV effects

77
Q

what body part should be protected and monitored during thyroidectomy

A

eyes

78
Q

s/s of thyroid storm (10) and when does it most often occur peri-op

A

temp >38.5c, HTN, tachy, confsion, agitation, tremor, weakness, arrhythmia, n/v, HF
-6-18h post op

79
Q

should you use salycilates for thyroid storm?

A

no it can displace T3/4 from proteins and raise levels further
-use tylenol

80
Q

what does PTH do

A

-increase calcium and decrease phos
-activates osteoclasts to break down bone to release cal
-activates vit d to promote cal absorption in GI tract

81
Q

effect of obesity on respiratory function

A

-restrictive ventilatory effect from excess weight. makes it harded for chest wall to expand and get air IN
-rapid shallow breathing

82
Q

is O2 consumption increased or decreased w obesity?
CO2 production?
why

A

-O2 consumption is increased and CO2 production is increased
-fat is metabolically active

83
Q

2 functions of adipose tissue

A

reservoir of usable energy, maintain heat/insulation

84
Q

when does adipose tissue become pathologic

A

when it releases free fatty acid and cytokines. this leads to end-organ injury, insulin reisitance, and inflammaation

85
Q

what lung volumes/capacity are decreased with obesity

A

TLC, VC, FRC, ERV, RV, IRV
(all except 1)

86
Q

what is the only lung vol/capacity increased with obesity?

A

closing volume

87
Q

what happens when FRC < closing volume

A

small airways collapse, causing VQ mismatch, shunting, hypercarbia, hypoxia

88
Q

what is the most senstive indicator of the effect of obesity on pulmonary function

A

ERV

89
Q

relationship of FRC and BMI

A

inverse

90
Q

effect of obesity on CO

A

CO is increased

91
Q

how does obesity lead to hypertension

A

release of inflamatory mediators –> increase RAAS/SNS –> vasoconstriction –> HTN, tachy, high CO

92
Q

is total blood vol increased or decreased w/ obesity?
is relative blood volume increased or decreased with obesity?

A

total is increased, relative is decreased

93
Q

whats EBV for obese

A

45ml/kg

94
Q

cause of excess adipose tissue

A

excess consumption & decreased activity

95
Q

how does obesity cause insulin resistance

A

high levels of free fatty acids in circulation block the transport mechanism so glucose cannot move into the cell

96
Q

android vs gynecoid fat

A

android: central, apple shape, assoc with inc O2 consumption, DM, and CV disease. more dangerous
gynecoid: peripheral, pear shape, fat is less metabolically active, less CV risk

97
Q

what measurement is now used for a standard marker of abdominal obesity? and what is # for M/F

A

-abdominal girth
Male >102cm
Female > 88cm

98
Q

BMI formula

A

wt (kg)/ht (m^2)

99
Q

obesity classifications

A

normal 18.5-24.9
over 25-29.9
obese 30+
class 1 = 30-34.9
class 2 = 35-39.9
class 3 = 40+

100
Q

concern with using TBW with obese

A

overdosing

101
Q

IBW formulas

A

M: IBW=height (cm)-100
F: IBW= ht (cm)-105

102
Q

LBW formula

A

LBW = IBW x 1.3
LBW accounts for body composition to an extent

103
Q

adjusted body weight

A

derivative of IBW used to prevent overdosing
-correction factor added to IBW
IBW + 20% or +40%

104
Q

issue with using IBW

A

under-doses

105
Q

what is the best weight to use with obese

A

LBW

106
Q

when using lipophilic drugs what weight is the best

A

LBW

107
Q

when using hydrophilic drugs what weight is best to use

A

IBW + 20%
(to acct for the increase in lean body tissue)

108
Q
A

NU 758 Adv Principles (5 decks)

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