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Coexisting conditions > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What drugs may potentially cause the onset of SLE?

A
  • hydralazine
  • procainamide
  • isoniazid
  • methyldopa
  • ppl who are slow acetylators are at higher risk
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2
Q

What physiologic stressors can exacerbate SLE?

A
  • Surgery
  • infection
  • pregnancy
    • poor fetal outcomes if mother has HTN and nephritis
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3
Q

What are the systemic problems with SLE?

(picture)

A
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4
Q

How is mild SLE treated?

A
  • NSAIDS for joint symptoms and pleurisy
    • must stop 2 days before surgery (bleeding)
  • low dose corticosteroids such as prednisone
    • for thrombocytopenia, hemolytic anemia, skin, arthritis symptoms
  • antimilarial drugs (hydroxychloroquine/quinacrine) and
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5
Q

How is severe SLE treated?

A
  • High dose steroids
    • this means you will probably need to give them a stress dose in the OR
  • immunosuppressive chemotherapy drugs
    • methotrexate
    • vincristine
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6
Q

Why does somebody who has been taking steroids require a stress dose of steroids for surgery?

A
  • Exogenous steroids prevent ppl from releasing cortisol when they encounter a stressor
  • As the stress of the surgery increases because the surgery is more major, you can give higher stress dose of hydrocortisone
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7
Q

What are airway management considerations for SLE?

A
  • There may be laryngeal involvement
    • leryngeal erythema and edema common
    • cricoarytenoid arthritis
    • mucosal ulceration
    • recurrent laryngeal nerve palsy
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8
Q

What do you need to consider when selecting anesthetic drugs for a pt with SLE?

A
  • Interactions with drugs used for SLE treatment
  • degree of organ dysfunction
    • impaired renal
    • hepatic clearance
    • cardiopulmonary involvement
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9
Q

What can you do to further reduce infections in pts with SLE?

Why is this a particular concern?

A
  • Strict asepsis technique with invasive procedures
  • maintain normothermia
    • help reduce infection
    • lessen impact of Raynaud’s if present
  • SLE patients are usually on immunosupressant medications
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10
Q

What anesthetic agents are best for SLE pts?

What should be avoided?

A
  • IA- do not depend of kidney for elimination
  • propofol and Etomidate are not significantly affected by renal impairment
  • Midaz ok in low doses
  • Opioids accumulate and prolong respiratory depression
    • sz with accumulation of meperidine
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11
Q

What are the cardiac manifestations of Rheumatoid arthritis?

A
  • dysrhythmia from rheumatoid nodules in the cardiac conduction system
  • cardiac valve fibrosis
  • pericarditis
  • myocarditis
  • coronary artery arteritis (similar to CAD, risk of MI)
  • Dilation of aortic root- aortic regurgitation
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12
Q

What are the pulmonary manifestations of Rheumatoid arthritis?

A
  • Pleural effusion and restrictive lung disease due to rheumatoid nodules in the lung tissue
  • decreased lung volume
  • pulmonary fibrosis (rare)
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13
Q

What are common surgical treatments for Rheumatoid arthritis?

A
  • Tendon release procedure, synovectomy, joint replacement
    • releive pain and restore joint function
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14
Q

What should you be aware of when managing the airway of a pt with rheumatoid arthritis?

A
  • document pre-op ROM limits, baseline symptoms of pain, numbness, and weakness
    • get MRI of neck
  • consider awake fiberoptic intubation
  • TMJ may affect mouth opening and cervical spine mobility, decreasing
  • Fixation/arthritis of cricoarytenoid joints:
    • voice changes or hoarseness
    • can make glottic opening difficult to identify or stenotic
    • require decreased tube size
    • edema may cause post-op airway obstruction
  • C-spine risk of Atlantoaxial subluxation
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15
Q

What is significant regarding the Cspine in patients with Rheumatoid arthritis?

How can this be determined?

A
  • Risk for Atlantoaxial subluxation (AAS)
  • The distance between anterior arch of the atlas to odontoid process (Dens) is > 3 mm on radiologic imaging
    • risk of slipping off
    • occurs in 25% of severe rheumatoid patients
    • risk of cervical spinal cord/medulla compression and interference with vertebral artery blood flow
    • need to be very careful when positioning for intubation (determine acceptable positions while pt is awake)
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16
Q

Anesthesia management of Rheumatoid arthritis

A
  • Anemia with cronic disease
  • effects of medications on platelet function
  • If pt has lung disease:
    • pre-op PFT, intraop ABG, post op ventilatory support
  • may need stress dose of corticosteroids
  • extubate with caution in those with cricoarytenoid arthritis
    • may want to have another intubation setup ready
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17
Q

Anesthetic conditions for pts with osteoarthritis

positioning

PMMA

A
  • positioning
    • support affected joints
    • position to minimize risk of injury
  • reconstructive surgeries use bone “cement” (PMMA)
    • space filler that holds the implant agains the bone
    • causes high pressures, pushes things into the blood, causing small emboli of fat and marrow
    • be prepared for drop in pressures
      • hypoxia, hypotension, dysrhythmias, PHTN, decreased CO
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18
Q

Osteo arthritis anesthetic considerations concering pheumatic tourniquets

A
  • Provide a bloodless field that greatly facilitates surgery
  • inflation pressure usually 100 mmhg over pts systolic blood pressure
  • prolonged inflation (>2hr) causes pain, nerve, damage
    • be careful not to treat this pain with too much opioids b/c it will be gone instantly when the turnequet is released
  • deflation may cause hemodynamic changes
    • can have them release slowly over time
  • notify physician that it has been on longer than 2hrs and document that
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19
Q

Which muscles are most affected by myesthenia gravis?

A
  • muscles innervated by cranial nerves
    • ocular
    • pharyngeal
    • laryngeal
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20
Q

What should you consider pre-operatively with a pt with myasthenia gravis?

A
  • Look at dose of pyridostigmine
  • assess pulmonary lung function
  • try to ease pt’s stress (psychologic and physical)
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21
Q

What is the rate of occurance of myesthenia gravis in men and women?

A
  • 1:7,500
  • women aged 20-30
  • men > 60yrs
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22
Q

What are the clinical features of myesthenia gravis?

presentation?

most affected muscles

cardiac involvement?

A
  • Presentation varies from mild weakness of limited muscle groups to severe weakness of multiple muscle groups
    • Class I- ocular MG
    • Class IV- severe, generalized MG
  • Ocular muscles are most commonly affected
    • Ptosis, dysphagia, and diplopia
  • Bulbar (brainstem)/laryngeal and pharyngeal muscle weakness
    • difficulty clearing secretions, pulm aspiration
  • myocarditis possible
    • a fib, heart block, cardiomyopathy
  • Severe disease associated with asymmetrical proximal muscle weakness (w/o atrophy)
    • Neck, shoulders, respiratory muscles
23
Q

What are the treatments for myesthenia gravis?

A
  • Oral anticholinesterase, maybe with steroid therapy
    • PO pyrostigmine
  • Corticosteroids- prednisone limits antibody production (second line therapy)
  • Thymectomy (median sternotomy or mediastinoscopy
  • Plasmapheresis- removes antibodies during crisis
    • depletes plasma esterase levels
    • prolonged effect of succ, mivacurium, ester-linked LAs
24
Q

What medications would you minimize or avoid in a myesthenia gravis pt?

A
  • benzos, opioids b/c pt is prone to weakness
  • aminoglycoside antibiotics can enhance weakness
25
Q

How would you plan to induce a pt with Myesthenia gravis?

A
  • Use short-acting agents (propofol)
  • Consider intubation without muscle paralysis
    • deep IA may be sufficient
    • topical lidocaine
    • NDMB potency increased 2x, reduce dose 33-50% if using
  • Aspiration risk- consider RSI
    • may increase Succ dose to 2 mg/kg to overcome resistance (anticipate prolonged effect)
    • if succ is used, NO NDMR until muscle function has returned and no fade present
    • do not give fasiculating dose
26
Q

If giving a NDMR to a pt with myesthenia gravis, where should you place the PNS?

A

Orbicularis oculi

27
Q

How should you provide the maintenance anesthesia to a pt with myesthenia gravis?

A
  • deep anesthesia with a volatile agent can provide sufficient relaxation for many surgical procedures
28
Q

What are some considerationf for emergence for a pt with myesthenia gravis?

A
  • They are at great risk for postoperative respiratory failure
  • advise pt that they may wake up with an ETT in place
  • Carefully evaluate ventilatory function prior to extubation
  • >5s head lift is a safe predictor
  • close observation in recovery
29
Q

What is Myasthenic syndrom?

What is it’s other name?

A
  • Lambert-Eaton myasthenic syndrome (LEMS)
  • pt presents with proximal muscle weakness
  • Usually develops in association with a neoplasm, but is also seen with other cancers or idiopathic autoimmune
    • often with small cell carcinoma of the lung
  • IgG antibodies form against the presynaptic voltage gate Ca++ channels
    • decreased release of ACh
  • If tumor is present, these antibodies are directed at the tumor but cross-react with the Ca++ channels
30
Q

Will an anticholinesterase help to reverse clinical effects of an NDMR in a patient with Myasthenic syndrome?

A
  • No! because ACh is not getting released from the vesicles, so there isnt any in the NMJ
31
Q

Difference between myesthenic syndrome and myesthenia gravis

(chart)

A
32
Q

What characterizes Duchenne’s muscular dystrophy?

A
  • symmetric proximal muscle weakness manifesting in gait disturbance
  • Kyphoscoliosis results from progressive weakness and contractures
  • weakness pronounced in proximal extremities
    • wheelchair bound by age 8-10, fatal by 20
  • cardiopulmonary dysfunction
    • degeneration of cardiac muscle
    • chronic weakness of inspiratory muscles (diff. clearing secretions)
  • reduced intestinal tract tone
    • decreased gastric emptying and increased aspiration risk
33
Q

why don’t you give Succ to kids?

A
  • because some kids have undiagnosed muscular dystrophy
  • When succ is given to somebody with muscular dystrophy, they can have severe rhabdomyalasis
  • can cause life threatening K levels
  • have of pts with MD who receive succ do not survive
34
Q

What clinical changes will you see in a pt with muscular dystrophy because of the cardiac muscle degeneration?

A
  • ECG abnormalities
    • atrial arrhythmias
    • prolonged P-R interval
  • decreased myocardial contractility and cardiomyoathy
  • mitral regurgitation from papillary muscle dysfunction
  • NEED CARDIAC WORKUP PRE-OPERATIVELY
    • EKG
35
Q

What clinical changes will you see in muscular dystrophy patients regarding pulmonary function?

A
  • Progressive respiratory muscle weakness
    • inadequate cough
    • frequent pulmonary infections
  • Kyphoscoliosis and muscle degeneration lead to a severe restrictive disease pattern
  • Sleep apnea is common
36
Q

Why is sleep apnea such a big deal?

A
  • Oxygen levels plumet, SNS kicks into fight or flight
    • all night long
  • pulmonary vasculature is exposed to low O2 levels
    • this causes vasoconstriction
    • this leads to pulmonary hypertension
  • These pts tend to be RSI
37
Q

What should you give to a muscular dystrophe patient preoperatively?

A
  • Avoid pre-op sedation or opioids
  • Give aspiration prophylaxis
    • antacid with H2 blocker or PPI
    • metoclopramide to reduce volume
    • antisialogogue like glyco
38
Q

How should you induce a pt with muscular dystrophy?

A
  • NO SUCCINYLCHOLINE!!
    • risk of inducing severe hyperkalemia, rhabdo, v-fib, cardiac arrest
    • MH
39
Q

What should you consider regarding maintenance anesthesia for a patient with muscular dystrophy?

A
  • they may have marked cardiopulmonary depression with IA
  • Normal or prolonged response to NDMR
  • anticipate post-op pulmonary dysfunction
    • prepare pt/family for possible ICU after surgery
  • Regional anesthesia may be preferable
40
Q

How is Marfan’s Syndrome treated?

A
  • Beta blockers are standard of care
    • reduce workload of the heart
    • delay/prevent AA and disection
  • Surgical procedures
    • elective aortic repair- recommended when the largest part of the aortic diameter is 4.5 cm
    • Spinal fusion for scoliosis
41
Q

What are anesthetic considerations for Marfan’s Syndrome?

A
  • focus pre-op assessment on cardiac abnormalities
  • Airway
    • visualization of larynx fine even with high arched palate and crowded teeth
    • TMJ dislocation risk because of joint laxity
    • tracheomalacia- floppy tracheal cartilage leading to tracheal collapse
    • Continuously monitor for pneumothorax
  • hemodynamic staility is critical!
42
Q

Why is it so important to control hemodynamics in pts with Marfan’s syndrome?

how can you do this?

A
  • Prevent sudden increase in myocardial contractility
    • this produces and increase in aortic wall tension
  • Avoid excessive endogenous catecholamine production
    • control pain and anxiety
  • treat hypertensive episodes immediately
  • VA can decrease the force of cardiac ejection
    • decrease the risk of aortic dissection
  • Ex: fentanyl and lidocaine before DVL
    • heavy propofol
    • esmolol to decrease HR
43
Q

How is Ankylosing spondylitis treated?

A
  • NSAIDS
  • exercise, PT
  • early diagnosis and treatment is essential to prevent permanent posture and mobility loss
  • surgery considered in patients with severe, advanced disease associated with refractory pain and disability
44
Q

How does ankylosing spondylitis affect management of the airway?

A
  • Difficult intubation if the AS involves the cervical spine
    • even more difficult if the TMJ is involved
  • limited mouth opening due to TMJ involvement
  • Significant risk of neurological injury with any excessive neck extension
  • progressive kyphosis and spine fixation may limit intubation
  • risk of occult cervical fracture with minimal trauma
  • cricoarytenoid arthritis- smaller tube
45
Q

What cardiac abnormalities are seen in a patient with Ankylosing spondylitis?

How might you anesthetize this patient?

A
  • aortic regurgitation
    • avoid sudden increases in SVR/keep HR > 90 and BP low/normal​
    • conduction abnormalities-BBB
    • Cardiomegaly
  • More benzos than opioids because opioids decrease HR more
  • use glyco with ephedrine to manage HR
  • Use etomidate
46
Q

What pulmonary abnormalities are seen with Ankylosing spondylitis?

A
  • Pulmonary fibrosis
  • apical cavity lesions
  • pleural thickening (similar to TB)
  • decreased compliance of chest wall
  • decreased vital capacity
47
Q

How would you manage the anesthesia for a pt with ankylosing spondylitis?

A
  • Management is influenced by severity of disease
    • upper airway involvement
    • presence of restrictive lung disease
    • degree of cardiac involvement
    • may be using neurologic monitors during corrective spinal surgery
  • awake fiberoptic tracheal intubation if spinal deformity is extensive
48
Q

Would you do a spinal or epidural on a pt with ankylosing spondylitis?

A
  • You can, but it is technically very difficult
  • may result in an increased risk of complications
  • consider paramedian approach
49
Q

What are surgeries that many patients with achondroplasia will be having done?

A
  • Sub-occipital craniectomy for foramen magnum stenosis
  • laminectomy- for spinal stenosis or nerve root compression
  • VP shunt- hydrocephalus
  • C-sections- required
    • cephalopelvic disproportion
    • kyphoscoliosis and narrow epidural space make epidurals difficult
      • no evidence based dosing guidelines, titrate slowly (weight based)
50
Q

What are evoked potentials?

What does this mean for the anesthesia you provide?

A
51
Q

What is an extra type of access you might want for a surgery with a pt with achondroplasia? Why?

A
  • Right atrial catheter
  • needed for a sitting craniectomy for foramen magnum stenosis
  • because the patient is sitting, if a vessel gets “nicked”, air can be entrained into the vascular system
  • you can remove this air using the right atrial catheter
52
Q

How do you select the appropriately sized ETT for a child?

A
  • age based: Age/4+4
  • weight based: wt (kg)/10+3.5
53
Q

What kind of cardiac/pulmonary issues would you see in a pt with achondroplasia?

A
  • Central sleep apnea (related to brainstem compression by foramen magnum and upper airway obstruction)
  • PHTN leading to cor pulmonale
54
Q

What are the challenges with airway management associated with achondroplasia?

A
  • Facial features can make mask ventilation difficult
  • larynx may be small, making intubation difficult
    • have range of tubes and difficult airway cart available
  • because of spinal conditions, must avoid hyperextension during intubation

Coexisting conditions (34 decks)

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