Test 3 Part 1 Flashcards
________________ is an autoimmune mediate systemic inflammatory disease with primary presentation of pain and disability associated with destruction of synovial joints
RA
what sex is affected more by RA?
Female 3x
this disease is characterized by morning stiffness that improves over the course of the day
RA
RA disease progression leads to
- destruction of cartilage
- periarticular osteopenia with pull off of ligamentous insertions –> deformities and instability
how do B lymphocytes and cytokines play a role in rheumatoid arthritis?
- activated endothelial cells attract molecules that stimulate T and B cells
- B cells produce autoantibodies (rheumatoid factor) –> enhanced cytokine production
- cytokines (TNF, IL1, and IL6) are released and accelerate the inflammatory cascade
questions you want to ask if patient presents with RA
- age of onset?
- recent hospitalizations?
- location and severity of joint dysfunction?
- Exacerbation triggers
- Current meds?
when assessing pt with RA, you ask about location and severity of joint dysfunction, what are parts of this specific assessment that you should pay close attention to as an anesthesia provider?
neck stiffness
crepitus
hoarseness
with RA the joints of the ____________ and _______________ are affected first; however the _____________ is the most common joint involved in the lower extremity
hand; wrists; knee
supportive treatment of RA includes
physical therapy
exercise
analgesics
anti-inflammatories
steroids
________________ are drugs that are used with RA to slow the progression and prevent deformities
disease-modifying antirheumatic drugs (DMARDs)
based on pathology of RA, what airway issues should you expect?
- tempromandibular joint disease and limited mouth opening
- arytenoid disease with deformity obstructing the glottic opening
- sjogrens is common –> poor dentition
- cervical spine stiffness
- vocal cord dysfunction
what are the four main features of cervical spine involement you may see/anticipate in someone with RA?
- atlantoaxial instability
- pannus –> mass effect on spinal canal
- ondontoid of C1 going into foramen magnum
- ankylosis with fusion of entire cervical spine
if patient with RA has ankylosis with fusion of the entire cervical spine; how would you intubate them?
in a neutral position with video laryngoscopy or awake/asleep video bronchoscopy
T/F: a patient with RA does not have any symptoms of spinal cord compression, therefore there is probably not any secondary to their disease
false; degree of compression may not correlate with patients symptoms
you have a patient who has had RA for 25 years, the surgery they are having will require manipulation of the neck through positioning and intubation. What should you ensure is done preoperatively?
lateral flexion and extension cervical spine radiographs (x-ray)
what labs would you consider in someone with RA?
CBC with plt
Renal fx test
what specific renal fx test would you do for someone with RA with chronic NSAID use?
creatinine
DMARDs for RA may cause a patient to be ______________________
neutropenic
what pulmonary tests would you consider in a patient with RA
PFT have secondary restrictive disease
what cardiovascular tests would you perfrom on a pt with RA
EKG
possible echo
possible stress test
T/F: if pt with RA comes into preop for elective surgery, and they are telling you their RA is really flaring up this morning, it would be best to delay
true
anesthesia considerations for the patient with RA
- difficult airway
- positioning concerns/risk of fractures
- regional anesthesia: peripheral nerve blocks okay, but challanging to do neuraxial block
sx of RA
1.malaise, weight loss, fever, fatigue
symmetry
2.polyarthropathy: TMj, limited jaw mobility, hoarseness, multijoint inflammation with morning stiffness
3. peripheral neuropathy/nerve entrapment
4. renal vasculitis
5. pancytopenia
what disease is defined as a chronic progressive disease of the joints of the spine and thorax that starts in early adulthood with inflammation of the sacroiliac joints and progresses cephalad eventually involving entire spinal column and ribcage
ankylosing spondylitis
what disease is often familial with strong association with HLA B27, and is more common in males
ankylosing spondylitis
24 year old male comes in complaining of lower back pain and buttock pain that is always worse in the morning. What should you suspect?
ankylosing spondylitis
progression of ankylosing spondylitis will lead to what complications with the musculoskeletal system?
- fibrosis and ossification of ligaments
- fusion and immobility of joints
- risk of spinal fractures especially with falls or careless movement
patient with severely progressed ankylosing spondylitis, you should be prepared for issues with ____________ and _____________, as well as know they are at increased risk of ______________
positioning; intubation; spinal fracture
a patient with ____________________ will show “bamboo spine” on radiographic images
ankylosing spondylitis
H&P for pt with ankylosing spondylitis
- location and severity of joint involvement - specifically cervical and thoracic spinal
- associated diseases
- assess fx’al capacity along with rest of body systems
- evaluate preop meds
what symptoms often accompany ankylosing spondylitis
- eye inflammation: uveitis/conjunctivitis (often unilateral)
- cardiac lesions: aortic valve insufficiency and RBBB
- pulmonary: looks restrictive on PFT, decreased compliance, hoarseness,
Tx of ankylosing spondylitis
stretching
exercise
PT
NSAIDs
DMARDs (specifically infliximab (remicade) and etanercept (enbrel))
what is the most common thoracic complication of ankylosing spondylitis
fixation of the thoracic cage d/t costovertebral ankylosis
physical exam of someone with ankylosing spondylitis
- pulmonary status
- restricted neck flexion and extension?
- thoracic kyphosis?
- asymmetric chest expansion?
- diastolic murmur?
if you have a patient with ankylosing spondylitis, and upon examination you hear a diastolic murmur, you know with this patient this is probably indicative of?
aortic insufficiency
when would you order a CXR on a patient with ankylosing spondylitis
if have significant kyphosis and respiratory dysfuction
when would you consider echo on pt with ankylosing spondylitis ?
if have murmur that needs to be evaluated
T/F: there are no specific lab or radiology tests indicated for ankylosing spondylitis
true
if patient with ankylosing spondylitis is on NSAID long term, what labs would you consider?
BUN & creatinine
if pt with ankylosing spondylitis is on Infliximab (leflunomide) what labs would you consider?
CBC-P d/t neutropenia
LFTs
what are the 4 different liver pathologies that can occur with infliximab (leflunomide)
- elevated transaminases and alkaline phosphatase/possible jaundice
- autoimmune liver dysfunction
- cholestasis
- reactivation of hepatitis B
when would you consider PFTs for pt with ankylosing spondylitis
- symptomatic (restrictive)
- chest wall expansion of <2.5 cm at level of 4th ICS
- those presenting for major surgery
T/F: with ankylosing spondylitis neuroaxial anesthesia is contraindicated
false; not contraindicated but may be difficult due to limited spinal flexion and ossification of ligaments
anesthesia considerations with ankylosing spondylitis
- airway - consider video laryngoscope, keep C-spine neutral, awake FOB
- positioning concerns - risk of fractures /c-spine immobility/thoracic kyphosis
- regional anesthesia - challenging neuraxial, peripheral nerve blocks
______________________ is a systemic autoimmune disease that can cause multiorgan damage; etiology is unclear but appears to be d/t genetic susceptibility with environmental/infectious agents that precipitate altered immune fx
systemic lupus erythematosus (SLE)
what causes the tissue damage with SLE?
deposition of immune complexes with activation of complement and other mediators of inflammation
incidence of SLE is more common in African American _________________. With peak age of onset ________________
women; 15-40
how do you diagnose SLE?
pt hx
clinical manifestations
pertinent immunologic lab studies/biopsy
relapsing-remitting dz
sx with SLE
- chronic fatigue/fever
- arthritis very common in small joints in hand and wrist/cricoarytenoid arthritis
- photosensitive “butterfly rash”
- alopecia
- raynauds
- pulmonary htn/restrictive dz
- lupus nephritis
- CVA/seizures
- immunosuppression
- pancytopenia/thrombus/prolonged apTT
T/F: elective surgery should be delayed in pt with SLE during flare up or with acute infectious process
true
preoperative considerations for pt with SLE
- optimize pulmonary status
- manage HTN
- consider peripheral nerve block
- drug considerations - consult with rhemuatologist regarding immunosuppresive agents and/or anticoagulants
- rarely issues with intubation; however, may see post-extubation edema or stridor
pts with active SLE chronically take steroids, this affects the __________________ system; and many patients present for ________________ procedures
musculoskeletal; orthopedic
anticipated complications for surgical pt with SLE
- increased transfusions
- hematomas/thrombosis
- infections
- prosthesis dislocation
- longer hospital stay
- DVT
- AKI
______________________ is a rare autoimmune mediated inflammatory vasculitis and fibrosis of skin and internal organs. 3x more common in females
scleroderma (systemic sclerosis)
what disease is associated with abnormal deposition of extracellular collagen due to impaired fibroblast fx. This leads to inflammation and obliteration of small arteries and arterioles
scleroderma
what age does scleroderma typically present?
middle age
T/F: the etiology of scleroderma is well studied and understood
false - etiology is unknown
what are the 3 main forms of scleroderma
- localized scleroderma (morphea)
- limited cutaneous systemic sclerosis
- diffuse cutaneous sclerosis
which type of scleroderma has an involvement of the skin of the face, the trunk and distal limbs, has sclerodactyly (sausage shaped fingers and toes that are red), and skin fibrosis that is complicated by necrosis
localized scleroderma (morphea)
which type of scleroderma is usually a combination of scleroderma features, presents with CREST syndrome, and has interstitial lung dz/pulmonary HTN
limited cutaneous systemic sclerosis
