Schmerler- N620 - Ans/pns

Front 1

1 in 1000 persons has ______, which could be primary or secondary, secondary or peripheral

Back 1

dysautonomia

Front 2

Intraoperatively, dysautonomia is characterized by _____ responses to many physiological and pharmacologic stimuli.

Back 2

paradoxical

Front 3

What diseases can cause primary autonomic failure?

Back 3

- MSA (multiple system atrophy)
- shy-drager
- parkinsons
- lewy body dementia
- autoimmune ganglionic neuropathy
- familial dysautonomia
- purre autonomic failure
- dopa beta hydroxylase deficiency

Front 4

What are the causes of secondary autonomic failure?

Back 4

- afferent baroreceptor failure
- DM
- spinal cord injury

Front 5

Proper functioning of the ANS requires intant ____ and ____ limbs.

Back 5

afferent and efferent

Front 6

What do afferent neurons do?

Back 6

detect changes in BP and temp, communicate these changes centrally

Front 7

What is afferent neuron dysfunction associated with?

Back 7

- labile HTN (baroreflex failure) particularly during postop period after endarterectomy or other neck surgeries affecting carotid sinus nerve

Front 8

What do efferent neurons do?

Back 8

engage effectors to perturb or restore homeostasis

Front 9

Abnormalities of central autonomic pathways such as in pts with ____, or efferent effector systems as in pts with ________, _______, or any combination thereof all can lead to clinical autonomic failure and _______.

Back 9

MSA,
pure autonomic failure,
pts with dopamine beta hydroxylase deficiency,
orthostatic hypotension

Front 10

Which pts are the most vulernable to the complex and interacting responses to drugs and perturbations that occur during anesthesia?

Back 10

MSA
extremely low BP upright, extremely high BP supine

Front 11

What are the hallmarks of autonomic dysfunction?

Back 11

1. orthostatic hypotension (at least 20/10 decr over 3 min in standing position)
2. major BP changes to trivial stimuli (DECR w standing, eating, hyprventilation, straining/valsalva, fever/heat, exercise, dehydration; INCR w lying supine, water ingestion, hypoventilation, abdominal binding, caffiene, t-berg)
- urinary bladder dysfunction (Retention), ED, GI immotility, supine natriuresis

Front 12

BP changes in autonombic dysfunction may be as great as...

Back 12

100/50!

Front 13

Supine HTN

Back 13

- >50% dysautonomic pts get severe HTN SBP <200 when supine
-supine natriuresis leads to orthostatic hypotension, accentuating HD lability
- possibly caused by residual sympathetic tone causing incr peripheral vascular resistance (Despite generally low NE and renin activity)

Front 14

What is denervation hypersensitivity?

Back 14

- pts w MSA, Shy-Drager/Autonomic failure have very LOW baseline NE/renin levels, fail to incr baseline plasma NE when challenged
- decr/absent neural traffic --> adrenergic receptor upregulation in vascular endothelium --> more dramatic in peripheral vs central dysautonomic dz.

Front 15

The ______ tests several components of the baroreflex arc.

Back 15

valsalva maneuver

Front 16

The increases in intrathoracic pressure seen during valsalva _______ stroke volume and BP.

Back 16

increases

Front 17

The valsalva will cause a _____ in BP and CO due to diminished ______ and reflex _____.

Back 17

decrease, venous return, tachycardia

Front 18

What happens when dysautonomics release their valsalva?

Back 18

BP overshoots d/t incr peripheral vascular resistance and CO

Front 19

In autonomic dz, the HR changes in phase 2 are _______, and phase 4 and BP are _______.

Back 19

attenuated/absent,
accentuated

Front 20

How is the valsalva maneuver test performed?

Back 20

- blow through closed mouthpiece w tiny leakage hole (16 gage)
- maintain 40 mmHg approx 15 sec
- 4 phases

Front 21

What is the effect of hyperventilation in dysautonomic pts?

Back 21

- yields sympathetic response during deep and rapid breathing for 30 sec to counteract systemic vasodilation induced hypocapnea
- significant decr in BP indicates failure/dysfunction

Front 22

Multiple System Atrophy (MSA)

Back 22

- primary dysautonomic dz
- rare, severe, SYNUCLEIOPATHY characterzied by alpha-synuclein protein aggregation in neural glia and cytoplasm
- degen./dysfcn of various CENTRAL AND PERIPHERAL NS structures
- develop multiple features: parkinsonism, cerebellar dysfcn, pyramidal signs

Front 23

How is MSA distinguished from Parkinsons?

Back 23

- presence of assymetric resting tremor
- poor response to levodopa
- rapidly progressive

Front 24

This is a subset of MSA characterized by degeneration of locus ceruleus, intermediolateral column of spinal cord, and PNS

Back 24

Shy Drager

Front 25

What is the diagnostic hallmark of Shy Drager?

Back 25

ANS degeneration evidenced by orthostatic hypotension, urinary/bowel retention, impotence

Front 26

In Shy Drager, the intermediolateral cell column exists at vertebral levels ____ thru ____ and mediates the entire sympathetic innervation of the body, but the nucleus resides in the _____.

Back 26

T1-L2,
medulla

Front 27

What secondary dysautonomic dzs can cause afferent baroreflex failure?

Back 27

- trauma, surgical trauma (carotid endarterectomy), carotid body tumor, glomus tumor on head/neck, brainstem stroke, cranial nerve damage s/p radiation therapy

Front 28

Acute afferent baroreflex failure resembles _____ more than autonomic failure. SBP swings to _____ can occur with seemingly normal stimuli.

Back 28

pheochromocytoma,
as high as 320

Front 29

What is Parkinsonian cardiac autonomic disorder?

Back 29

- severe depletion of dopaminergic neurons of the nigrostriatal system --> movement disorder

Front 30

How do you provide a "Thoughtful anesthetic" during dysautonomia?

Back 30

- understand impact of decr ANS activity on CV responses to events such as changes in body position, positive airway pressure, and acute blood loss (during surgery)
- choose pharm agents w consideration for CV impact

Front 31

How can you ensure HD stability for dysautonomic pts during surgery?

Back 31

- preop hydration (preinduction fluid bolus)
- maintain euvolemia
- maintain current meds, dont be afraid to treat VS fluctuations
- check multiple pre-induction BPs (BP normal in sitting, take BP 1,3,5 min after supination to expose instability)

Front 32

Inpatient _____ will worsen orthostatic changes during general anesthesia in dysautonomic pts.

Back 32

deconditioning

Front 33

In pts with autonomic dysfcn, any structural lesion of the adrenergic pathways can cause ______. These pts can tolerate lower standing BPs without dizziness/collapse, probably because....

Back 33

orthostatic hypotension,
cerebral blood flow preserved from autoregulation

Front 34

In MSA, autoregulation of CBF seems to be preserved down to a SBP of ____, well below the _____ at which autoregulation fails in normal subjects.

Back 34

60, 80

still treat hypotension rapidly!

Front 35

Should you be aggressive in controlling orthostatic fluctuations?

Back 35

yes! fix promptly

Front 36

Hypotension and vasodilation without signs of autonomic compensation require...

Back 36

vigilance!

Front 37

What can you do to treat hypotension during orthostatic fluctuations?

Back 37

head up or down maneuvers
responsive to phenylephrine (sensitive to low doses, esp. in peripheral dysautonomia)

Front 38

Supine HTN may require treatment, but avoid _____.

Back 38

long-acting agents

Front 39

Carefully dosed precedex, NTG, and nicardipine are better choices for dysautonomic HTN than...

Back 39

labetalol or hydralazine

Front 40

Liver blood flow in dysautonomics is ____ and ____ Dependent, which may affect hepatically cleared drugs.

Back 40

posture and pressure

Front 41

Plasma levels of ______ infusion can reach toxic levels depending on a dysautonomic pts position.

Back 41

lidocaine

Front 42

Which pressors have the greatest effect in dysautonomics?

Back 42

phenylephrine, norepi, and vasopressin

Front 43

What are the airway complications associated with dysautonomic pts?

Back 43

- assume GI motility issues until proven otherwise (RSI)
- in MSA, may display muscle rigidity, vocal cord paralysis, and central resp dysregulation --> complicates intubation and post op ventilation
- additional postop risk for obstruction, aspiration and hypoventilation

Front 44

When does orthostatic hypotension become less of an issue during general?

Back 44

after positioning is complete

Front 45

Anesthesia can suppress any residual _____ neural traffic in dysautonomic pts, disturbing crucial counterregulatory compensation in the face of surgical trauma.

Back 45

sympathetic

Front 46

The loss of CV reflexes predispose autonomic pts to...

Back 46

- dramatic BP changes in response to rapid volume status changes (fluid bolus and blood loss)
- HR may stay fixed in spite of BP changes
- a-line, flow-trac

Front 47

How can you adjust your ventilator to optimize hemodynamics in dysautonomics?

Back 47

- positive pressure ventilation often elicits sympathetic response, but doesnt in these pts -- consider baseline effect of venous return and CO
- minimize PEEP bc it inhibits venous return
- goal to keep CO2 normal, hypoCO2 causes hypotension, hyperCO2 causes HTN

Front 48

What are the goals of temperature regulation intraoperatively for dysautonomics?

Back 48

- lose ability to sweat or vasoconstrict in reponse to temp change, complicating temp regulation already impaired under anesthesia
- hyperthermia --> hypotension d/t vasodilation
- hypothermia can persist without autnomic compensation (Esp DM)
- may have postop fever

Front 49

Hypotension from spinal anesthetic is typically ______ but easily _____. Therefore, its important to consider ____ effect on hemodynamic status prior to initiating regional.

Back 49

exaggerated, treated,
positioning's

Front 50

For autonomics receiving regional, ___ and ____ Trump technique.

Back 50

euvolemia and vigilant monitoring

Front 51

PREOP AUTONOMIC DYSFCN CONSIDERATIONS

Back 51

- Ortho hypotension with or without supine HTN
- possible gastroparesis and aspiration risk (RSI)
- awareness of blood volume status and prep for blood tx PRN
- preinduction fluid bolus

Front 52

INTRAOP DYSAUTONOMIC ANESTHESIA CONSIDERATIONS

Back 52

- GA vs RA mostly equivocal
- hyper/hypo thermia both pose risks
- positioning may significantly affect Hemodynamics
- if severe supine HTN, use NTG, reverse t-berg, precedex, pronation
- suddent volume changes pos or neg will yield dramatic HD changes
- avoid pneumoperitoneum
- pressors may be exaggerated or blunted
- replete electrolytes

Front 53

POSTOP DYSAUTONOMIC ANESTHESIA CONSIDERATIONS

Back 53

- anticipate volume changes and observe closely
- ensure adequate blood volume to avoid orthostatic events
- ensure maint of normothermia
- ileus exacerbated by opioids
- restart home meds before D/C

Front 54

Glomus tumors

Back 54

- neuroendocrine tumor appears in head and neck
- originates in tissue along carotid, aorta, glossphopharyngeal nerve, middle ear (location dictates s/s)
- may be secretory (NE - pheomimetic, cholecystekinin - postop ileus, serotonin/kallikrein - carcinodimimetic)

Front 55

Unlike pheochromocytomas, glomus tumors do not secrete ____ because they lack the ___ necessary to convert NE to ___. Administration of ______ may be used preop to lower BP and facilitate volume expansion in pts with incr serum NE.

Back 55

epi, transferase, epi, phenoxybenzamine or prazosin

Front 56

Secretion of ____ by the duodenal and intestinal mucosa is stimulated by protein or fat rich ____ entering the duodenum. It then inhibits gastric ____ and _____ and mediates digestion in the duodenum.

Back 56

CCK, chyme,
emptying and acid secretion,

Front 57

Which is inappropriate as an initial treatment for HTN d/t neuroendocrine tumor in prep for surgical removal?
nitroprusside,
metoprolol, phenoxybenzamine, doxazosin?

Back 57

metoprolol -- want to lower SVR before vasodilating
bc decr myocardial contractility in the setting of incr SVR will result in heart failure! (always lower SVR prior to beta blockade)

Front 58

When prepping pt for general anesthesia to resect a carcinoid tumor, which drug should be selcted and why?
- thiopental
- vecuronium
- atracurium
- morphine

Back 58

vecuronium (no histamine release)

carcinoid tumors often release histamine, so avoid histamine -releasing drugs

Front 59

What is the care plan for a glomus tumor pt?

Back 59

- standard monitors, A-Line, large bore IVs, possible central line (Consider tumor location)
- anticipate hyper/hypotension, ensure euvolemia
- pheomimetic glomus tumor: Na nitroprusside, phentolamine, nicardipine, mag, clevidipine, vasopressin
- carcinoid glomus tumor: octreotide (100 mcg/hr)
- intraop: incr VAE risk (monitor w precordial doppler/echo, etco2), avoid NMB if surgeon monitoring facial nerves

Front 60

Idiopathic facial nerve palsy (bell's palsy)

Back 60

- rapid paralysis of muscles innervated by facial nerve
- presumed to be inflammation and edema of facial nerve, most often in facial canal of temporal bone
- viral inflammatory mechanism (HSV) may be cause
- surgical decompression (in severe bell's, trauma)

Front 61

Bell's Palsy pts are likely to be on which medication?

Back 61

prednisone

Front 62

Facial nerve palsy has been described following placement of ____ to treat ______.

Back 62

blood patch, PDPH

Front 63

Trigeminal Neuralgia (Tic Delaroux)

Back 63

- brief intense unilateral face pain triggered by sensory stimuli to ipsilateral side of face
- likely caused by nerve root compression by abnormal blood vessel

Front 64

What is the drug of choice for trigeminal neuralgia?

Back 64

anticonvulsant carbamazepine

also use baclofen and lamotrigine

Front 65

For trigeminal neuralgia pts, you should anticipate ____ during nerve fiber destruction, and _____ from anticonvulsant therapy.

Back 65

hypertension,
hepatic enzyme induction

Front 66

Glossopharyngeal neuralgia

Back 66

- episodes of intense pain in throat, neck, tongue and ear
- severe brady and cardiac syncope reflecting activation of motor nucleus of vagus
- hypotension
- seizures d/t cerebral ischemia and possible cardiac arrest

Front 67

What is the anesthetic mgmt for glossopharyngeal neuralgia?

Back 67

- antimuscarinic prior to laryngoscopy
- LTA prior to intubation
- anticipate hypovolemia and CV abberations intraop
- have trancutaneous/venous pacer ready
- potential for vocal cord paralysis from surgical trauma may precipitate obstruction after extubation

Front 68

Charcot-Marie Tooth Dz (CMT1A, Chuck Mantooth Dz)

Back 68

- most comon 1:2500 inheritied chronic motor/sensory neuropathy
- distal skeletal muscle weakness, wasting loss of tendon reflexes
- presents mid-teen yrs

Front 69

Charcot Marie Tooth Dz does not cause ____ but has risks with ___ Administration.

Back 69

MH, succ

Front 70

Brachial plexus neuropathy (AKA idiopathic brachial neuritis, parsonage-turner syndrome, shoulder-girdle syndrome)

Back 70

- inflammatory/immune patho
- acute onset
- initial severe pain in upper arm, followed by patchy paresis of skeletal muscles innervated by brachial nerve

Front 71

What is the anesthesia consideration for brachial plexus neuropathy?

Back 71

autoimmune neuropathies may be provoked from surgical stress

Front 72

Guillain Barre Syndrome (acute idiopathic polyneuritis)

Back 72

- sudden onset of skeletal muscle weakness/paralysis that manifests initially in legs and spreads cephalad over ensuing days to arms, trunk, and face
- serious cases involve intercostal and pharyngeal muscle weakness impairing ventilation
- may resolve spontaneously

Front 73

What are the anesthesia considerations for chronic cases of guillain barre syndrome?

Back 73

- anticipate autonomic lability
- adrenergic and cholinergic receptor upregulation
- controlled airway
- avoid succ!

Front 74

DM is commonly associated with ______. The longer the hyperglycemia/ hypoinsulinemia is sustained, the greater the extent of _____.

Back 74

peripheral polyneuropathy,
neuropathy

Front 75

Nerve conduction velocity _____ secondary to hyperglycemia.

Back 75

slows

Front 76

Hyperglycemia induces _____ proinsulin producing bone marrow derived cells that travel to the PNS, where they fuse with ____ Cells and ____ neurons, causing neuronal dysfunction and death.

Back 76

fusogenic, schwann cells and dorsal root ganglion neuron

Front 77

_____ is a key anesthetic consideration for pts with diabetic polyneuropathy.

Back 77

positioning

Front 78

The peripheral nerves of pts with DM are more vulnerable to _____ due to compression or stretch injury often despite padding and positioning during these periods.

Back 78

ischemia

document and get informed consent!

Front 79

What is the most clinically significant type of diabetic neuropathy?

Back 79

diabetic autonomic neuropathy

complex, multifactorial patho

Front 80

DM autonomic neuropathy is more common in...

Back 80

poorly controlled long-standing diabetics

Front 81

____ Stress from hyperglycemia initiates a cascade of cellular mayhem, resulting in....

Back 81

oxidative stress,
results in direct nerve damage and microcirculation damage

Front 82

What are the factors involved in the deveopment of DM autonomic neuropathy?

Back 82

hyperglycemia causes:
- incr free radicals
- decr NO
- incr protein kinase C
- decr Na-K ATPase

Front 83

S/S of diabetic neuropathy that can be identified on assessment?

Back 83

- loss of HR variability w deep breathing (early sign)
- resting tachy (late parasymp destruction)
- exercise intolerance
- orthostatic hypotension
- QT abnormalities (predispose to torsaades!)
- HTN
- silent ischemia/infarct
- CV instability intraop

Front 84

For pts with _____, its not what you use but how you use it with drugs.

Back 84

diabetic autonomic neuropathy

Front 85

For diabetic autonomic neuropathy, you should expect and anticipate...

Back 85

post induction hypotension (MAP decr 30) -- esp in pts taking ACEIs! (-prils)

stimulation w laryngoscopy wont always fix this, give small amts of phenylephrine PRN

Front 86

What are the induction techniques for diabetic autonomic neuropathy?

Back 86

higher fi02 60%
get preinduction rhythm strip
cardiac style induction (high opioid, low IV agent, low IA, a-line PRN)