T3 - Neuro Disease Assessment Flashcards
What is the first step in managing patients with neurological disorders before anesthesia?
Conduct a thorough assessment, including reviewing the patient’s history, symptoms, and neurological deficits.
What should be included in the diagnostic evaluation of patients with neurological disorders before anesthesia?
Review imaging and neurological testing results to understand the extent of the neurological condition.
Why is it important to review the patient’s current drugs and treatments before anesthesia?
To assess potential drug interactions, side effects, and their impact on anesthesia.
What should be considered when assessing the potential risks and benefits of various anesthetic options?
Factors such as the patient’s neurological condition, comorbidities, and the type of surgery should be evaluated.
How can the patient’s condition be optimized before anesthesia?
Implement preoperative measures such as medication adjustments, neurological interventions, and addressing any modifiable risk factors.
Why is clear preoperative documentation important in patients with neurological disorders?
It ensures that all relevant factors, including the patient’s history, diagnostic findings, medication review, and chosen anesthetic plan, are documented with a rationale.
What is Multiple Sclerosis (MS)?
MS is a progressive autoimmune disorder characterized by the demyelination of central nerve fibers.
What is the typical onset age for Multiple Sclerosis?
MS typically begins between the ages of 20 and 40.
What are the risk factors associated with Multiple Sclerosis?
Risk factors include being female, having a first-degree relative with MS, Epstein-Barr virus (EBV) infection, other autoimmune disorders, and smoking.
What are the common symptoms of Multiple Sclerosis?
Symptoms include motor weakness, sensory disorders, visual impairment, and autonomic instability. Symptoms vary depending on the site of demyelination.
What factors can trigger exacerbations of Multiple Sclerosis?
Triggers include stress, elevated temperatures, and the postpartum period.
What is the typical disease course of Multiple Sclerosis?
MS is characterized by periods of exacerbations and remissions.
Is there a cure for Multiple Sclerosis?
No, there is no cure for MS. However, it can be managed with corticosteroids, immune modulators, and targeted antibodies.
What is the first step in preanesthetic considerations?
Assess existing deficits in the patient’s condition.
What should be considered if the patient has respiratory compromise?
Consider pulmonary function tests to assess respiratory function.
Which laboratory tests are typically ordered before anesthesia?
CBC with platelets, basic metabolic panel (BMP), and optionally liver function tests (LFT) if the patient is on Dantrolene or Azathioprine.
Why is close attention to glucose and electrolytes necessary before anesthesia?
Steroids may impact glucose and electrolyte levels, so monitoring is crucial.
When should preoperative steroids be considered?
Consider preoperative steroids in patients with long-term steroid use.
Why is temperature management critical before anesthesia?
An increase in body temperature can precipitate exacerbations of Multiple Sclerosis symptoms.
What are the acceptable anesthetic options for patients with Multiple Sclerosis?
General anesthesia (GA), regional anesthesia (RA), and peripheral nerve blocks (PNBs) are acceptable options.
Why should Succinylcholine be avoided in multiple sclerosis patients?
Succinylcholine may induce hyperkalemia and should be avoided in patients with Multiple Sclerosis.
What is Myasthenia Gravis (MG)?
MG is an autoimmune disorder characterized by antibodies generated against N-Ach-R’s at skeletal motor endplates.
Which type of muscle does MG affect?
MG primarily affects skeletal muscle, not smooth or cardiac muscle.
What are the common symptoms of MG?
Symptoms include muscle weakness exacerbated by exercise, cranial nerve involvement (especially ocular symptoms like diplopia and ptosis), and bulbar involvement leading to respiratory insufficiency and aspiration risk.
What is common in Myasthenia Gravis patients related to the thymus?
Thymic hyperplasia is common in MG patients, and approximately 90% of patients improve after thymectomy.
What factors can exacerbate symptoms of Myasthenia Gravis?
Symptoms can be exacerbated by pain, insomnia, infection, and surgery.
What are the treatment options for Myasthenia Gravis?
Treatment may include acetylcholinesterase inhibitors (Pyridostigmine), immunosuppressive agents, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG).
How does thymectomy affect Myasthenia Gravis?
Over 90% of patients improve after thymectomy.
What is the first step in preanesthetic considerations for Myasthenia Gravis?
Assess existing deficits in muscle strength and respiratory function.
What should be considered if there is respiratory compromise?
Consider pulmonary function tests to evaluate respiratory function.
How should respiratory function be optimized before anesthesia?
Optimize respiratory function to reduce the risk of respiratory compromise during and after anesthesia.
What precaution should be taken with neuromuscular blocking agents (NMBs)?
Reduce NMB dosage to avoid prolonged muscle weakness and respiratory depression.
Why should caution be exercised with opioids in Myasthenia Gravis patients?
Use opioids cautiously to avoid respiratory compromise, especially in patients with compromised respiratory function.
How do acetylcholinesterase (Ach-E) inhibitors affect neuromuscular blocking agents and local anesthetics?
Ach-E inhibitors may prolong the effects of Succinylcholine and ester local anesthetics.
Which laboratory tests are typically ordered before anesthesia in Myasthenia Gravis patients?
Order CBC, BMP, and optionally LFT (if on Azathioprine) to monitor glucose and electrolyte levels.
When should preoperative steroids be considered in Myasthenia Gravis patients?
Consider preoperative steroids in patients with long-term steroid use to prevent adrenal insufficiency.
What should be discussed with Myasthenia Gravis patients before surgery?
Counsel patients on the increased risk of needing postoperative respiratory support or ventilation until fully recovered from anesthesia.
What is Eaton-Lambert Syndrome?
Eaton-Lambert Syndrome is a rare autoimmune disorder characterized by autoantibodies against voltage-gated calcium channels, leading to reduced calcium influx and decreased acetylcholine release.
What is a significant association of Eaton-Lambert Syndrome?
More than 60% of cases are associated with small cell lung carcinoma.
What are the common symptoms of Eaton-Lambert Syndrome?
Symptoms include progressive limb-girdle weakness, dysautonomia, oculobulbar palsy, and may resemble those of Myasthenia Gravis.
How is Eaton-Lambert Syndrome treated?
Treatment options include
- Selective potassium channel blockers like 3,4-diaminopyridine, acetylcholinesterase inhibitors, immunosuppressive agents such as Azathioprine, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG).
What is the first step in preanesthetic considerations for Eaton-Lambert Syndrome?
Assess existing deficits in muscle strength and respiratory function.
What should be considered if there is respiratory compromise?
Consider pulmonary function tests to evaluate respiratory function.
How does Eaton-Lambert Syndrome respond to neuromuscular blocking agents?
Eaton-Lambert Syndrome is very sensitive to both non-depolarizing and depolarizing neuromuscular blocking agents, with significantly higher sensitivity to non-depolarizing agents compared to Myasthenia Gravis.
What should be done to optimize respiratory function before anesthesia?
Optimize respiratory function to reduce the risk of respiratory compromise during and after anesthesia.
Why should extreme caution be exercised with neuromuscular blocking agents and opioids?
Exercise extreme caution with neuromuscular blocking agents and opioid dosing to prevent respiratory compromise.
What should be discussed with Eaton-Lambert Syndrome patients before surgery?
Counsel on risks for needing post-op resp support until fully recovered from anesthesia
What is Muscular Dystrophy?
Muscular Dystrophy is a hereditary disorder characterized by muscle fiber degeneration due to breakdown of the dystrophin-glycoprotein complex, leading to myonecrosis, fibrosis, and increased skeletal muscle membrane permeability.
How many types of Muscular Dystrophy are there?
There are six types of Muscular Dystrophy, each with its own characteristics and genetic mutations.
What is the most common and severe form of Muscular Dystrophy?
Duchenne Muscular Dystrophy is the most common and severe form, occurring only in boys with onset typically between 2-5 years of age. Patients are usually wheelchair-bound by age 8-10 and have an average lifespan of around 20-25 years due to cardiopulmonary complications.
What are the common symptoms of Muscular Dystrophy?
Symptoms include progressive muscle wasting without motor/sensory abnormalities, kyphoscoliosis, long bone fragility, respiratory weakness, frequent pneumonia, and EKG changes.
What laboratory findings would be elevated in muscular dystrophy as a result of muscle wasting?
Serum creatine kinase levels are often elevated due to muscle wasting and damage.
What is myotonia?
Myotonia is a prolonged contraction after muscle stimulation, commonly observed in several muscle disorders.
What is the most common form of myotonia?
Myotonic Dystrophy is the most common form of myotonia, typically manifesting in the 20-30s with muscle wasting in the face, masseter, hand, and pre-tibial muscles. It may also affect pharyngeal, laryngeal, and diaphragmatic muscles, and can lead to cardiac conduction abnormalities. Approximately 20% of patients have mitral valve prolapse.
What is Myotonia Congenita?
Myotonia Congenita is a milder form of myotonia characterized by skeletal muscle involvement while smooth and cardiac muscles are spared.
What is Central Core Disease?
Central Core Disease is a rare condition where core muscle cells lack mitochondrial enzymes, leading to proximal muscle weakness and scoliosis.
What triggers myotonias, and how are the symptoms managed?
Myotonias are triggered by stress and cold temperatures. Symptoms are managed with medications such as Quinine, Procainamide, and steroids, although there is no cure for these conditions.
What laboratory tests should be considered pre-anesthesia for myotonic dystrophies?
Pre-operative EKG and echocardiogram should be performed to evaluate for cardiomyopathy.
How should neuromuscular blockade be approached in patients with Myotonic Dystrophies?
Exercise caution with non-depolarizing neuromuscular blockers, and ensure careful monitoring throughout the procedure.
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What syndrome, similar to Malignant Hyperthermia, can be seen with succinylcholine and volatile anesthetics?
Hypermetabolic Syndrome can occur, leading to life-threatening hyperkalemia and arrhythmias, particularly with succinylcholine use.
Why should succinylcholine and volatile anesthetics be avoided in patients with Myotonic Dystrophies?
Succinylcholine and volatile anesthetics can exacerbate instability of the muscle membrane, leading to complications.
What should be assessed regarding cardiac and pulmonary function pre-anesthesia?
Assess the extent of cardiac and pulmonary abnormalities through thorough evaluation, including auscultation of breath and heart sounds for abnormalities.
How does GI hypomotility impact the risk of aspiration?
GI hypomotility increases the risk of aspiration, necessitating careful management to mitigate this risk.
What endocrine abnormalities in MD should be considered pre-anesthesia?
Assess thyroid and glucose levels due to the high risk of endocrine abnormalities in patients with Myotonic Dystrophies.
Why is it important to keep MD patients warm pre-anesthesia?
Keeping patients warm helps to avoid flares of symptoms associated with Myotonic Dystrophies.
What should be done to optimize respiratory status pre-anesthesia in MD patients?
Optimize respiratory status to reduce the risk of postoperative respiratory weakness, a common complication in patients with Myotonic Dystrophies.
Why should depolarizing (Succs) neuromuscular blockers and opioids be used cautiously in MD patients?
Depolarizing neuromuscular blockers should be avoided because fasciculations can trigger myotonia. Caution should also be exercised with opioids.
What laboratory tests should be considered pre-anesthesia?
Consider CBC (Complete Blood Count), BMP (Basic Metabolic Panel), PFTs (Pulmonary Function Tests), and CK (Creatine Kinase) levels.
What are the three major dementia syndromes?
The three major dementia syndromes are Alzheimer’s (70%), Vascular dementia (25%), and Parkinson’s (5%).
What assessment should be conducted regarding cognitive function?
Assess the level of cognitive dysfunction in patients with dementia.
How should informed consent and decision-making be approached?
- Patient may not be able to give informed consent, look to medical PoA
- Investigate any advanced directives for medical decision-making
What evaluations should be conducted pre-operatively?
Perform basic labs and pertinent tests/imaging to assess the patient’s medical condition.
What is the potential risk related to aspiration?
Patients with dementia may have an increased risk of aspiration due to a full stomach, necessitating careful management.
Why is it important to review pre-operative medications?
Review pre-operative medications, especially those that may affect anesthesia, such as acetylcholinesterase inhibitors, MAOIs, and psychotropic medications.
What is an increased risk post-operatively in patients with dementia?
Patients with dementia are at an increased risk of post-operative delirium, which should be carefully monitored and managed.
How should opioids be managed in patients with dementia?
Balance opioids to meet analgesic needs without exacerbating delirium. Regional anesthesia may be preferred to reduce opioid requirements.
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What is Parkinson’s disease characterized by?
Parkinson’s disease is characterized by the degeneration of dopaminergic fibers in the basal ganglia.
What is considered the biggest risk factor for Parkinson’s disease?
Advanced age is considered the biggest risk factor for Parkinson’s disease.
How does dopamine normally regulate the extrapyramidal motor system?
Dopamine regulates the extrapyramidal motor system by inhibiting excess stimulation, which is primarily driven by acetylcholine.
What are the main symptoms that comprise the triad of Parkinson’s disease?
The triad of symptoms in Parkinson’s disease includes skeletal muscle tremor, rigidity, and akinesia.
What are some treatment options for Parkinson’s disease?
Treatment options include
- Levodopa (which crosses the blood-brain barrier),
- Anticholinergics
- MAOIs (which inhibit dopamine degradation)
- Deep brain stimulation.
What are some other symptoms commonly associated with Parkinson’s disease?
Other symptoms include
- Rhythmic “pill rolling” tremors
- Facial rigidity
- Slurred speech
- Difficulty swallowing
- Respiratory difficulty
- Depression
- Dementia
What are the clinical features of a middle cerebral artery stroke?
Contralateral hemiparesis and hemisensory deficit (face and arm more than leg), aphasia if it affects the dominant hemisphere, and contralateral visual field defect.
What are the clinical features of a posterior cerebral artery stroke?
Contralateral visual field defect and contralateral hemiparesis.
What are the clinical features when penetrating arteries are occluded?
Contralateral hemiparesis and contralateral hemisensory deficits.
What are the clinical features of a basilar artery stroke?
Oculomotor deficits and/or ataxia with crossed sensory and motor deficits.
What are the clinical features of a vertebral artery stroke?
Lower cranial nerve deficits and/or ataxia with crossed sensory deficits.
How is the nidus size of an AVM graded in the Spetzler-Martin system?
Nidus size is graded as small (<3 cm) for 1 point, medium (3-6 cm) for 2 points, and large (>6 cm) for 3 points.
What does eloquence of adjacent brain mean in the Spetzler-Martin AVM grading system?
Eloquent brain areas are those that, if affected, would result in a significant neurological deficit. Eloquent areas score 1 point, while noneloquent areas score 0 points.
The pattern of venous drainage is graded as superficial only for 0 points and deep only or deep and superficial for 1 point.
What is the likelihood of no postoperative neurological deficit with a Spetzler-Martin AVM grade of 1?
There is a 100% chance of no postoperative neurological deficit with a Spetzler-Martin AVM grade of 1.
How does the Spetzler-Martin AVM grade correlate with the percentage of patients with no postoperative neurological deficit?
Grade 1 correlates with 100% of patients having no deficits,
- Ggade 2 with 95%
- Grade 3 with 84%
- Grade 4 with 73%
- Grade 5 with 69% having no postoperative neurological deficits.
