wk 6 brain/SC/ANS Flashcards
- Question: Scenario: A 55-year-old patient with a history of hypertension is undergoing craniotomy for tumor resection. Intraoperatively, the patient’s mean arterial pressure (MAP) drops to 60 mm Hg, and the intracranial pressure (ICP) is noted to be 20 mm Hg. Question: What is the cerebral perfusion pressure (CPP) in this patient, and what is the expected physiological response?
40mmHg, cerebral ischemia
- Question: Scenario: A patient with traumatic brain injury (TBI) exhibits elevated ICP. The anesthetic plan includes the use of propofol for its cerebral effects. Question: What is the primary effect of propofol on cerebral physiology in this context?
Propofol reduces CBF, CBV, and ICP due to cerebral vasoconstriction
- Question: Scenario: During neurosurgery, a patient is intentionally hyperventilated to achieve a PaCO2 of 30 mm Hg. Question: How does acute hypocapnia affect cerebral blood flow (CBF) and intracranial pressure (ICP)?
Hypocapnia causes vasoconstriction, which reduces cerebral blood flow and reduces ICP
- Question: A 60-year-old patient with a history of chronic hypertension is undergoing a craniotomy. What is the expected alteration in cerebral autoregulation?
HTN causes the autoregulation curve to shift to the right, so the pressure of dependence of CPP occurs at a higher CPP (upper & lower limit)
- Question: During a neurosurgical procedure, a patient develops sudden hypertension and bradycardia. This response is most likely due to:
cushing’s reflex (Response to elevated ICP, reflex to brain ischemia. triad: HTN (wide PP), irregluar respiration, bradycardia)
- Question: A patient with a head injury shows signs of uncal herniation. The initial anesthetic management should focus on:
maintain CPP
(Methods to decrease ICP
Elevate head, Hyperventilation (achieve PaCO2 of 30-35), CSF drainage, Administration of hyperosmotic drugs, diuretics, corticosteroids, cerebral vasoconstricting anesthetics (like propofol), surgical decompression)
- A 45-year-old patient with a history of brain tumor presents with signs of increased ICP. Which of the following is the most likely initial compensatory mechanism the body employs to maintain cerebral perfusion in the face of rising ICP?
Compensatory CSF displacement
(Monro-Kellie hypothesis: changes in 1 compartment are compensated by changes in another until a certain point where small changes have profound effect on ICP)
- In a patient with transtentorial herniation, which clinical sign would most likely be observed first due to its pathophysiological mechanism?
ipsilateral oculomotor dysfunction
(also causes Altered LOC, defects in gaze & afferent ocular reflexes, hemodynamic & respiratory compromise, and death)
- Question: A patient with increased ICP shows signs of nausea, vomiting, and papilledema. These symptoms are most directly related to:
nonspecific signs of ICP ???
- Question: Which type of Lundberg wave is indicative of the most severe intracranial pathology and is associated with poor outcomes?
A-wave: plateau-waves w/ abrupt increases in ICP from 20-100mmHg lasting up to 20min
- In managing a patient with sustained increased ICP, why is hyperventilation to maintain PaCO2 near 30 to 35 mm Hg recommended over more aggressive hyperventilation?
cause other adverse effects systemically (cerebral ischemia & stroke bc reduced CBF can compromise perfusion to areas that are already ischemic)
-effects of hyperventilation only last 6 hours. Risk for rebound increase in ICP after.
- A patient with increased ICP is receiving mannitol. Which of the following is a critical consideration in its administration?
If serum osmolarity is > 320mOsm/L, do NOT give any more mannitol
- In a patient with elevated ICP following traumatic brain injury, why are corticosteroids generally not recommended?
NOT effective for nonvasogenic edema
- A 55-year-old male with a chronic C5 spinal cord injury is scheduled for elective surgery. Which anesthetic management consideration is paramount due to his level of injury?
Monitor for autonomic hyperreflexia (common w injury above T6)
- Propofol is used in the management of increased ICP. Its effectiveness in reducing ICP is primarily due to its ability to:
reduce CMRO2
- Question: A patient with Friedreich ataxia is undergoing spinal surgery. What anesthetic consideration is most critical due to the associated cardiomyopathy?
use low-dose inotropic support (CM + anesthetics that are negative inotropes = risk of compromise)
- In a patient with spontaneous intracranial hypotension presenting for surgery to repair a CSF leak, what is the most significant anesthetic consideration?
Risk for rebound intracranial HTN after sx repair requiring therapeutic LP
- Question: A 55-year-old patient with a history of post-polio syndrome is scheduled for elective surgery. Which of the following anesthetic considerations is essential due to the patient’s condition?
Sensitive to non-depolarizing NMBDs, avoid high doses
(extreme sensitivity to sedative effects of anesthesia & delayed awakening from GA)
- Question: A 25-year-old patient with a newly diagnosed low-grade astrocytoma is scheduled for a surgical resection. The patient has been experiencing new-onset seizures. What is the most important anesthetic consideration for this patient?
Avoid meds that lower the seizure threshold
- Question: A patient with a high spinal cord injury presents for surgery. Which anesthetic technique would be most appropriate to prevent autonomic hyperreflexia?
High spinal anesthesia.
- Question: A patient with glioblastoma multiforme has undergone surgical debulking. Which postoperative strategy is most important for this patient?
Strict BP control to avoid hemorrhagic complication
- Question: When planning anesthesia for a patient with ALS, which of the following considerations is most pertinent due to the risk of hyperkalemia?
No succ
- Question: During the postoperative management of a patient who has undergone evacuation of a subdural hematoma, which of the following blood pressure targets is MOST appropriate to prevent rebleeding?
<140
- Question: For a patient with a known history of syringomyelia, which of the following anesthetic plans should be carefully considered due to potential impaired autonomic regulation?
Continuous epidural anesthesia
- Question: A 70-year-old patient with a history of poliomyelitis in childhood is scheduled for total knee arthroplasty. Which of the following anesthetic considerations is most crucial due to postpolio sequelae?
extreme sensitivity to sedative effects of anesthesia & delayed awakening from GA
- Question: A 40-year-old patient with a T4 spinal cord injury is undergoing minor open abdominal surgery. Which anesthesia approach is most appropriate to prevent autonomic hyperreflexia?
High thoracic epidural anesthesia
- Question: During an elective craniotomy for epilepsy, what is the most appropriate anesthetic management to avoid seizure exacerbation?
sevo
- Question: A patient with a history of spinal cord injury at T5 presents with severe hypertension and bradycardia during a below-the-knee amputation. What is the initial best management step?
Use of a short-acting antihypertensive (clevidipine)
- Question: When considering spinal anesthesia for a postpolio patient, what is the most important consideration?
Possible increase sensitivity to LA requiring dose adjustment
- Question: For labor analgesia in a parturient with a T4 spinal cord injury, which of the following would be the preferred method to prevent autonomic hyperreflexia?
low-dose combined spinal-epidural anesthesia
- Question: For a patient with a history of seizures and controlled hypertension, which antiepileptic agent would be most concerning in the perioperative period?
valproate: assoc with surgical bleeding (thrombocytopenia & decreases in vWF & Factor 8)
- Question: A patient with a complete T4 spinal cord injury is undergoing elective surgery. Post-operatively, which symptom would indicate the onset of autonomic hyperreflexia as the anesthesia wears off?
HTN & bradycardia
- Question: Scenario: A patient with multiple system atrophy (MSA) presents for surgery. MSA has led to significant autonomic dysfunction, including orthostatic hypotension and impaired baroreceptor function. Question: What anesthetic management strategy is most appropriate for this patient?
Manage hypotension with IVF or direct-acting vasopressors (neo is preferred)
- Question: A patient with Multiple System Atrophy (MSA) is scheduled for surgery. What is the most appropriate anesthetic management regarding blood pressure control?
treat promptly w/ fluids and vasopressors (direct acting preferred)
- Question: A patient with a history of Postural Orthostatic Tachycardia Syndrome (POTS) is undergoing a minor surgical procedure. Which anesthetic management strategy is most appropriate to prevent perioperative complications?
Pre-op IVF
+ low dose neo gtt ready
- Question: During surgery for a patient with Postural Orthostatic Tachycardia Syndrome (POTS), which drug should be used cautiously to avoid exacerbating the condition?
phenylephrine
- Question: A patient with a diagnosed paraganglioma is undergoing tumor resection. Which of the following should be included in the anesthetic plan?
Give phenoxybenzamine or prazosin preoperatively
- Question: In managing a patient with Paraganglioma, which of the following is the most critical preoperative assessment?
Urinary catecholamine metabolites to determine if tumor secretes catecholamines or serotonin
Catecholamine metabolites → NE/epi → use phenoxybenzamine or prazosin
5-HIAA → serotonin → use octreotide
- Question: A patient with a diagnosed paraganglioma is undergoing surgery. If intraoperative hypertension occurs, which of the following management strategies is most appropriate?
Rapidly titratable anyihypertensives: clevidipine, nipride, nicardipine
- Question: What is the preferred method of anesthesia in patients with Carotid Sinus Hypersensitivity undergoing carotid endarterectomy?
Regional anesthesia
(Causes exaggerated activity of baroreceptors in response to mechanical stimulation → syncope)
- Question: A patient with Guillain-Barré syndrome (GBS) requires emergency surgery. Question: What is a key consideration in the anesthetic plan for this patient?
Patient may need post-op mechanical ventilation even if not required pre-op
- Question: Anesthetic Considerations for POTS and Intraoperative Tachycardia. A patient with POTS develops significant tachycardia during a surgical procedure. Which of the following would be an appropriate management strategy?
beta blockers
- A patient with a history of traumatic brain injury is exhibiting signs of Paroxysmal Sympathetic Hyperactivity (PSH) during surgery. Which of the following would be the most appropriate initial management step?
Admin of BB
(PSH (aka autonomic storm, sympathetic storm, & dysautonomia): tachy, hyperthermia, HTN, tachypnea, sweating, hypertonia, posturing)
- In a patient with familial dysautonomia undergoing surgery, why is rapid sequence induction preferred?
Increased aspiration risk due to GERD
(Aka Riley-Day syndrome: hereditary ANS disorder: autonomic crises in response to stress)
- Which of the following is a crucial consideration during anesthetic emergence in a patient with familial dysautonomia?
ensure adequate NMBD reversal
(hypotonia = aspiration risk)
- In a patient undergoing microsurgical decompression for trigeminal neuralgia, what intraoperative complication should be closely monitored?
Bradycardia from activation of the trigeminocardiac reflex
- A patient with glossopharyngeal neuralgia is undergoing surgery. What preoperative consideration is most critical?
Assess cardiac status: possibility of syncope or bradycardia
- After intracranial transection of the glossopharyngeal nerve in a patient with glossopharyngeal neuralgia, which of the following is a potential postoperative complication?
VC paralysis
- Question: A patient with Guillain-Barré syndrome is undergoing surgery. Due to autonomic nervous system dysfunction, which of the following anesthetic considerations is most critical?
Avoid DL to prevent dramatic increases in BP
- Question: In a patient with Guillain-Barré syndrome, which muscle relaxant is most appropriate to use?
Vec or cis bc minimal effect on circulatory system
- Question: Why might a patient with Guillain-Barré syndrome require mechanical ventilation postoperatively, even if breathing spontaneously before surgery?
Progressive muscle weakness affecting respiratory muscles
- Question: A patient with CRPS (Chronic Regional Pain Syndrome) in the upper limb exhibits excessive sweating and changes in skin color in the affected area. These symptoms are
Dysregulation of the SNS (motor & autonomic dysfunction)
- Question: In a patient with CRPS, which of the following pathophysiological mechanisms primarily contributes to the allodynia often observed in these patients?
CNS sensitization
- Question: A 60-year-old patient with a long history of poorly controlled diabetes mellitus is undergoing surgery. The patient reports numbness and tingling in the lower extremities. What anesthesia-related complication is this patient at increased risk for?
Peripheral nerve injury from compression or stretch
- Question: A patient with vitamin B12 deficiency undergoing anesthesia is at increased risk for which of the following?
Prolonged effect of NMBDs
- Question: A patient with AIDS-associated neuropathy requires anesthesia for a surgical procedure. What is a key consideration for this patient regarding anesthesia management?
Potential for altered response to LAs
- A male patient undergoing abdominal surgery develops ulnar neuropathy postoperatively. Which of the following factors is most likely to have predisposed him to this condition?
Preexisting obesity & nerve conduction abnormalities
- In a patient who underwent surgery in the lithotomy position, which nerve is most at risk for perioperative neuropathy?
Common peroneal nerve from pressure near fibular head
- A patient experiences postoperative brachial plexus neuropathy. Which surgical position is most likely to have contributed to this complication?
Sternal retraction during median sternotomy, steep trend, and prone w/ shoulder abduction and contralateral head rotation
- When assessing a patient with suspected peri-operative peripheral neuropathy, what is the most critical initial step?
Thorough H&P (identify RF or hx of peripheral neuropathy)
- In a patient with purely sensory deficit postoperatively, what is the suggested management approach?
Sensory deficits resolved within 5 days, therefore expectant management is suggested
