Week 12 - Skin & MSK Disorders

Question 1

Anesthetic management of a pt w/ Epidermolysis Bullosa

4

Answer 1

• Avoid skin trauma (Tape, Etoh prep pads, chloraprep)
• Corticosteroids & Regional anesthesia indicated
• Lubricate the Laryngoscope blade
• Smaller than usual ETT

Question 2

Concern around Pemphigus patient’s and surgery?

Answer 2

Chronic fluid losses
* Dehydration
* Hypokalemia

due to self-induced NPO

Question 3

Chronic urticaria pts should avoid what medications?

Answer 3

• NSAIDs
• ACEi
• Aspirin

Question 4

Anesthetic implications for a pt w/ Urticaria?

Answer 4

• Avoid Histamine releasing drugs (Morphine,Atracurium)
• Pre-op H1-, H2-receptor antagonists, & corticosteroids
• Warm room & IV fluids

Question 5

What are the processes that characterize Scleroderma?

Answer 5

• Inflammation & auto-immunity
• Vascular injury -> vascular obliteration
• Fibrosis in organs & tissues

Question 6

What is Crest syndrome?

Answer 6

Scleroderma’s eventual destination
C - calcinosis
R - Raynaud’s
E - Esophageal hypomotility
S - Sclerodactyly
T - Telangiectasia

Question 7

Anesthetic implications for a pt w/ Marfan Syndrome?

4

Answer 7

• Avoid TMJ dislocation
• Avoid sustained ↑ in SBP (during DL/Surgical stimulation) due to risk of Ao. dissection
• Consider invasive monitoring (TEE)
• Monitor for Pneumothorax

Question 8

Main difference of Dermatomyositis from Polymyositis?

Answer 8

Dermatomyositis includes skin changes along with muscle weakness

Question 9

Main difference of Polymyositis from Dermatomyositis?

Answer 9

Polymyositis associated w/ other connective tissue disorders
* SLE
* Scleroderma
* RA

4

Question 10

Anesthetic considerations for Polymyositis and Dermatomyositis?

3

Answer 10

• Risk for pulmonary aspiration (Weak cough/unable to clear secretions)
• Response to NMBs normal
• But muscle weakness + residual NMB -> poss. difficulty weaning from Mechanical ventilation

Question 11

What respiratory manifestation is most concerning from the myopathies?

Answer 11

Paresis of Pharyngeal muscles
* Dysphage
* PNA
* Aspiration

4

Question 12

Factors indicating possible need for post-op Mech. Ventilation in transsternal thymectomy?

Answer 12

1. > 6 year MG diagnosis
2. COPD unrelated to MG
3. Pyridostigmine dose >750mg
4. Vital Capacity < 2.9L

Question 13

Pre-op anesthetic implications in Myasthenia Gravis?

Answer 13

Tell pts they may need to remain intubated 2/2 muscle weakness

Question 14

Pyridostigmines (and other anticholinesterase drugs) may have what effect on NMBs?

Answer 14

• Succinylcholine: prolonged response & ED95 is 2.9x ↑
• NDNMBs: antagonize (more needed)

Question 15

What is the physiological effect MG pathophysiology has on NMBs?

Answer 15

• Increased sensitivity to NDNMBs due to ↓ AchRs destroyed by antibodies
• Resistant to Succinylcholine due to ↓ AchRs + pyridostigmine

Question 16

Induction anesthetic implications for MG?

Answer 16

• Short acting IV anesthetic acceptable
• Endotracheal intubation may be accomplished w/o NDNMBs 2/2 intrinsic muscle weakness + relaxant effect of Volatile agents

Question 17

Maintenance anesthetic implications for MG?

Answer 17

• Avoid Opioids 2/2 prolonged respiratory effects
• ↓ need for NMBs
• VA +or- N2O

Question 18

Emergence anesthetic implications for MG?

Answer 18

Postpone extubation until clear evidence of respiratory function is present

Question 19

Will pyridostigmine be effective in the treatment of Myasthenic Syndrome, why or why not?

Answer 19

No.
Anticholinesterase drugs do not produce improvements due to ↓ pre-synaptic Ca2+ influx after depolarization -> ↓ Ach release

Question 20

What is the physiological effect Myasthenic Syndrome pathophysiology has on NMBs?

Answer 20

• Succinylcholine & NDNMB sensitivity due to ↓ release of Ach & ↑ AchR sensitivity to activation