test 3 part 4 Flashcards
T/F: the pathogenesis of ALS is debatable. Could be genetic, environmental, autoimmune and/or viral
true
what is the median time of survival of ALS after dx
3-5 years
T/F: 5-10% of cases of ALS have a familial component
true
ALS anesthesia implications
- preop testing guided by comorbidities
- Risk of dehydration and aspiration
- respiratory compromise
- End of life care, intubation, and reuscitation
what lab is typically evaluated in pts with ALS
creatine phosphokinase (CPK) due to chronic muscle wasting
what drug anesthetic induction drug should be avoided in pts with ALS
succ
if pt with ALS is coming in for surgical procedure, what should you advise them to bring with them?
NIPPV
in a pt with ALS you should be aware of autonomic dysfunction, which will have what clinical sx?
- resting tachycardia
- orthostatic hypotension
- elevated circulating levels of epi/norepi
what is the dose of phenytoin given for seizure d/o
400 mg/day
for a seizure d/o what is the therapeutic phenytoin level?
10-20 mcg/ml
what are the adverse effects/toxicity sx with phenytoin
ataxia
drowsiness
gum hyperplasia
macrocytic anemia
steven johnson syndrome
what is the dose of carbmazepine for seizure d/o
600 mg/day
for seizure d/o what is the therapeutic level of carbmazepine (tegretol)
4-8 mcg/ml
what are the adverse/toxicity sx for carbamazepine (tegretol)
- N/D
- rash
- Dizziness
- hyponatremia
- blood dyscrasias
- steven johnson syndrome
what is the dose of phenobarbital for seizure d/o
120 mg/day
for seizure d/o what is the therapeutic level of phenobarbitol
10-35 mcg/day
what is the dose of ethosuximide for seizure d/o
1000 mg/day
For seizure d/o what is the therapeutic level for ethosuximide (zarontin)
40-100 mcg/ml
what is the dosage of lamotrigine (lamictal) for seizure d/o
300-500 mg/day
what is the dosage for levetiracetam (keppra) for seizure d/o
2000 mg/day
for seizure d/o what are the adverse effects/toxicity sx of phenobarbitol (luminal)
drowsiness
nystagmus
rash
what are the adverse effects/toxic sx for Ethosuximide (zarontin) in the tx of seizure d/o
drowsiness
nausea
rash
bone marrow depression
what are the adverse/toxicity effects of lamotrigine (lamictal) in the tx of seizure d/o
dizziness
ataxia
blurred vision
stevens johnson syndrome
what are the adverse effects/toxicity sx of levetiracetam (keppra) in the tx of seizure d/o
somnolence
dizziness
what drugs are used to Tx partial seizures
carbmazepine
phenytoin
vigabatrin
lacosamide
valproate
what meds are used to tx generalized seizure d/o
carbamazepine
phenytoin
valproate
barbiturates
gabapentin
keppra
lamotrigine
T/F: all antiepileptic drugs are metabolized in the liver
false; all except gabapentin
what meds would we (as anesthesia) give if a patient goes into status epilepticus during surgery
propofol
lorazepma
phosphenytoin
diazepam
midazolam
what is the role of the nurse anesthetist if pt is in status epilepticus during surgery
- prevent seizure
- tx seizure
- manage the airway and hemodynamic status
if pt is in status epilepticus what medication should be avoided
neuromuscular blockade
___________ seizure is where you have neuronal discharges originating from one point of the cerebral hemisphere
focal/partial
_____________ seizure is one that arises from both cerebral hemispheres
generalized
what are the different classifications of seizures?
focal/partial
generalized
unknown
what are triggers for seizures if you have seizure d/o
sleep deprivation
poor diet
stress
menstruation
acute illness
noncompliance with meds
you have a patient have a patient who is in status epilepticus in the OR, you need to intubate what should you do?
administer antieplieptic anesthetic (propofol or thiopental) to temporarily halt seizure activity
what is common sequela of ongoing seizure activity?
metabolic acidosis
seizure d/o preoperative considerations
- hx of seizure type, triggers, frequency, most recent activity, meds, testing and imaging results
- are AEDs/anticonvultants at therapeutic level
- no contraindications to regional anesthesia
you have a patient presenting with seizure d/o, you know anticonvulsants have ____________ properties and are _________________, thus you know that the pt may require more ________________
sedative; liver enzyme inducers; anesthesia
T/F: a patient with a seizure d/o should NOT take their anticonvulsants day of surgery due to the sedative effects
false; they should continue anticonvulsants day of surgery
Seizure anesthesia implications/considerations
- pt should take antiepleptic meds DOS
- pre medicate with benzos
- avoid drugs that lower the seizure threshold
- know that inhalation agents can provoke seizure like activity
- know what drugs are burst suppresants
you have a pt with known seizure d/o; they are intubated and sedated. How would you know they were seizing since a lot of anesthestic meds are burst suppressants?
increase in end-tidal CO2 and may result in patient respiratory efforts
if a seizure occurs in the OR, how should you as the anesthesia provider handle it?
- ensure oxygenation and ventilation are maintained (turn on side if need to prevent aspiration)
- give meds for control of seizure activity
- protect patient from injuries secondary to seizure
- ensure no toxic effects from antieplieptic meds
_________________ is an autoimmune disease caused by antibodies which attack the postsynaptic acetylcholine receptor at the neuromuscular junction
myasthenia gravis
myasthenia gravis has been associated with other autoimmune diseases such as:
throiditis
hematologic autoimmune d/o
RA
SLE
describe the way patients with undiagnosed myasthenia gravis present
present with proximal muscle weakness with is alleviated by rest and exacerbated by activity
with _________________, 60% of patients present with diplopia, ptosis or both; bulbar muscles may be impaired resulting in dysphagia
myasthenia gravis
what is the first line therapy for myasthenia gravis
pyridostigmine (cholinesterase inhibitor)
what are the treatments for myasthenia gravis
- thymectomy
- anticholinesterase medications (pyridostigmine)
- immunosuppressants
- plasmaphresis +/- IVIg
if pt has myasthenia gravis due to thymoma, is under 45 years of age, and is + for serum-anti-acetylcholine receptors, what is the treatmetn
thymectomy
what is a myasthenic crisis
exacerbation of Myasthenia gravis; worsening muscle weakness, and respiratory insufficiency
patient with myasthenia gravis present with severe muscle weakness and respiratory insufficiency. You give a dose of edrophonium, which causes a worsening of symptoms. You know this is diagnostic for?
cholinergic crisis
what is the difference in myasthenia crisis and cholinergic crisis
- autonomic symptoms may be present (bronchospasm, bronchorrhea, diarrhea, sialorrhea) with cholinergic
- dose of edrophonium will worsen symptoms in cholinergic
what causes a cholinergic crisis?
anti-cholinesterase overdose
what are the sx with cholinergic crisis
- muscle weakness and respiratory insufficiency
- additional sx: bronchospasm, sialorrhea, bronchorrhea, cramping, diarrhea
what are the risk factors for myasthenic crisis
- osserman stage >2b
- previous hx crisis
- symptoms >2 years
- lung resection
- high antibody titer
- BMI > 28
administering _________________ in the preoperative period stage reduces postoperative myasthenic crisis and postop pulmonary complications
high dose glucocorticoids
myasthenia gravis anesthesia implications
- elective surgery only performed in stable pts
- neurology consult
- Aspiration prophylaxis
- They are VERY sensitive to sedation and/or potentiate muscle weakness
- avoid NMB if can
- avoid succ
T/F: sugammadex is safe to use in patients with myasthenia gravis
true
what predicts the need for postoperative ventilatory support for pt with myasthenia gravis
- had the disease for > 6 years (12 pts)
- hx of chronic respiratory dz (10 pts)
- pyridostigmine dose > 750 mg/day (8pts)
- Vital Capacity < 2.9 L (4 pts)
- Total score of >/= 10 indicates increased risk of postop ventilation for at least 3 hours
_______________ is a rare, autoimmune-mediated d/o of the neuromuscular junction where autoantibodies are direct against voltage gated p/q type calcium channels on the presynaptic nerve terminal
lambert-eaton syndrome
