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Principles of Anesthesia Exam III
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73
Nursing
Graduate
07/30/2009

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Cards

Term

Malignant hyperthermia definition (fill in the blanks)

 

________ hyper _________ state in _______

Tissue following exposure to a

__________________

Definition
Acute hyper metablolic state in muscle tissue following exposure to triggering agents.
Term
What is the fatality rate of Malignant hyperthermia if treated vs. untreated?
Definition

Untreated fatality > 70%

 

Treated (in timely manner) 4%

Term
Describe the pathophysiology of M.H.
Definition
  • Defect in either the dihydropyridine or the ryanodine receptor
  • Non-physiologic stimuli (ie: drugs) opens receptor and it stays open a long time
  • Causes prolonged Ca++ release (huge amounts) from S.R.
  • Large amts. of intracellular Ca++ Cause prolonged interaction between actin and myosin filaments
  • Leads to increased/ prolonged interaction between actin and myosin filaments.
Term
In M.H. what are the secondary effects associated with the increased muscle metabolism/ contraction?
Definition
  • muscle rigidity
  • increased lactic acid
  • increased CO2 production
  • Muscle breakdown
Term
What are triggering agents for MH?
Definition

Halothane

Sevoflurane

Isoflurane

desflurane

Succinylcholine

 

Possible heat/ exercise

Term
What agents are considered "safe" in regards to MH?
Definition

Opioids

Non-depolarizing muscle relaxants

Ketamine

Propofol

Anxiolytics

Nitrous Oxide

Term

Pediatric incidence of MH?

 

Adult incidence?

 

Overall Incidence?

Definition

peds: 1: 15,000

 

Adults: 1: 40,000

 

Overall: 1:10,000

Term

Where are the high incidence areas in the U.S.?

 

Definition
West Virginia, Wisconsin, and Michigan (Thumb)
Term

True or False;

 

MH is an autosomal dominant disorder.

Definition
True
Term

You are in pre-op and your patient says, "I have had surgery under general anesthesia before, and I didn't have any problems."

 

Should you worry about M.H.?

Definition

You should at least be "suspicious"

Because nearly 50% of patients with MH have had a previous uneventful surgical anesthetic.

Term

What is the most specific and sensitive sign of M.H. in the O.R.?

 

What can mask this sign?

 

 

Is this a late sign or an early sign?

Definition

Sudden rise in ETCO2 is the most specific and sensitive sign of M.H.

 

Can be masked by hyperventilation

 

Considered the earliest sign of MH

Term

What are the initial signs of M.H.?

 

 

What can cause you to miss these signs?

Definition

Initial: tachycardia and tachypnia

 

can be missed because these are usually blunted by general anesthetic drugs

Term
Pull finger as you flip this card.
Definition
Term
Besides ETCO2, Tachycardia and tachypnia what are the other signs tell me that my pt. has MH?
Definition

Increase in BP

 

Vent. Dysrhythmias

 

Muscle rigidity (80%) of cases

 

Increase in body temp: 1-2 degrees every 5 minutes

 

CO2 absorbent activation (will get very hot!)

Term

What will I see on ABG with "classic" MH?

 

 

Definition
CO2 retention and metabolic acidosis
Term
In MH what labs are outta whack?
Definition

Hyperkalemia

 

Hypercalcemia

 

lactic acidosis

 

myoglobinuria

 

Elevation of creatine kinase exceeding 20,000 (CK) within first 12-24 hours

Term

Okay so I got this guy-

Almost died, but we saved him because we gave him a crap ton of Dantrolene. 

Now he is stable-

 

I report to the ICU nurse not to worry because we fixed him.  Is this statement entirely true?  Why or why not?

Definition

Not entirely true.  The ICU nurse should be vigilant as this syndrome can reappear in 24 to 36 hours.

 

We also have a problem now with myoglobinuria which can lead to renal failure and possible DIC

Term
What can accelerate the manifestation of MH?
Definition
Succs used in conjunction with a volatile anesthetic.  symptoms may be seen in 5-10 minutes.
Term

Rigidity of the jaw muscles after the administration of succinylcholine is called what?

 

More common in adults or children?

 

At what ages does this problem peak?

Definition

Masseter Muscle Rigidity (MMR)

 

More common in children

 

Peaks between ages of 8-12

Term

True or False?

 

Additional doses of Succs or NDMRs may be needed in order to relieve Masseter Muscle Rigidity.

Definition
False.  Additional Doses of succs or NDMRs will not relieve the spasm.
Term

Why do I care about Masseter Muscle Rigidity?

 

 

What if it coincides with limb rigidity?

Definition
25% of people having MMR test positive for Malignant hyperthermia.  If limb rigidity is involved the association of M.H. increases!!!!!!!!!!!!!!!!!
Term
Besides M.H. what are some other causes of masseter muscle rigidity? 
Definition

1. Myotonic syndrome

 

2. Temporomandibular joint dysfunction

 

3. Underdosing Succs

 

4. Intubating before succs works

 

5. increased succs tension in presence of fever or elevated plasma epinepherine.

Term
There are 3 levels of rigidity for Masseter muscle rigidity (MMR)  what are they?
Definition

1. Mild (Normal response to depolarization)

 

2. Moderate  (Can still intubate and ventilate)

 

3. JAWS OF STEEL (AHHH!)

Term

Don't spaz out but Um.. your pt's masseter muscle IS spasming...

 

What now?

Definition

DON'T PANIC

 

1. If possible d/c anesthetic and postpone surgery

 

2. If continuing surgery move to anesthetic with non triggering agents (TIVA)

 

3. Pt should be observed for 12-24 hours for myoglobinuria and signs of M.H.  Dantrolene may be considered 1-2 mg/kg

 

4. Keep family informed of episode of MMR and potential risk for M.H.

 

5. Ck levels should be checked q 6 for 24 hours.

 

6. If CK levels >20,000 perioperatively and myopathy is not present- diagnosis of MH is very likely.  If negative- family members not usually tested.

Term

According to the M.H. organization:

 

What happens to kids with Duchennes and Becker's muscular dystrophy?

 

What type of M.H. is this?

Definition

Kids with muscular dystrophy have succs. induced hyperkalemia that is NOT associated with M.H.

(so there is no type of M.H.-trick question)

 

This hyperkalemia is dangerous however (60% death) and needs to be treated like other hyperkalemic events.

Term

Core Central Disease (CCD) is a congenital myopathy characterized by ________________ and is a result of a mutation in the ______________

receptor. 

 

What complication is CCD associated with?

Definition

Muscle weakness

 

ryanodine receptor

 

 

Several cases of MH have been associated with CCD.

Term

True or False:

 

All pts with Central Core Disease (CCD) should have alternative anesthetics (ie: No volatiles)

Definition

True- High incidence of M.H.

 

Probably would avoid succs. as well.

Term

Besides Core Central Disease,

 

What other defects or disorders would cause me to be suspicious of M.H.?

Definition

The myotonias (Steinherts dx, hypo/hyperkalemic periodic paralysis and others)

 

King Denborough syndrome: marked slanted eyes, low set ears, pectus deformity, scoliosis, small in stature

 

Osteogenesis imperfecta

 

Strabismus or the presence of ptsosis

 

[image]

Term

[image]-----> you see this waveform

 

You notice your pt's temp is increasing

 

You touch the Absorbant and damn near burn your finger to the nub.....

 

Pucker factor has increased to Defcon 4 What now?

Definition

Holy Crap it might be Malignant hyperthermia!

 

Some hot dude better give iced fluids fast ladies!

 

1.  Stop volatile

-purge circuit

-change the absorbant

 

2.  Hyperventilate with 100% O2 at 10L/min

 

3. Dantrolene: 2.5 ml/kg q 15 unit symptoms resolve up to 10 mg/ kg

 

4. Bicarbonate for severe metabolic acidosis

-2-4 meq/kg

 

5. Glucose/insulin/hyperventilation/bicarb/ Ca Chloride 10 mg/kg or 1 gm IV for arrhythmias (following hyperkalemia treatment guidlines)

 

6. IV fluids (without K ie: NO LR), ice  packs, cooling blankets, cold gastric lavage

 

7. Furosemide- flush kidneys

(accounting for rhabdomyolysis producting myoglobinuria)

 

8. Tachycardias:

Lidocaine is the drug of choice. 

 

9.  Lab data

Term
When do you stop cooling efforts in MH?
Definition
38 degrees C.
Term

1) What drugs (for tachycardias) should be avoided in MH and why?

 

 

2) When do arrythmias usually resolve in MH?

Definition

1) Calcium Channel Blockers should not be used.

 

Verapamil will react with Dantrolene causing hyperkalemia

 

2) When the pt is dead or hypercarbia and hyperkalemia resolve

 

 

 

Term

1) How does dantrolene work?

 

 

 

2) How is it dosed? 

 

 

3) Oh Yeah smart ass?  How do you reconstitute it?

 

 

 

 

Definition

1) directly in the muscle cell and binds on the ryanodine receptor and reduces the release of Ca++ from the SR

 

2)  2.5 mg/kg IV can repeat until symptoms resolve up to 10 mg/kg.  Repeat dose after 4-6 hours

 

3) 20 mg vials are reconstituted w/ 50-60 mls of STERILE WATER

Term

True or False: (and explain why please)

 

1) While treating an episode of M.H. you notice arrhythmias. One of the culprits is more than likely the Dantrolene.

 

 

2) When using Dantrolene you probably want a foley catheter

Definition

1) False.  Dantrolene has little effect on the myocardium in prescribed doses

 

 

2) Dantrolene contains 300 mg of mannitol per vial.  Furthermore- you are already going to be worried about Rhabdo.

Term

36 vials of Dantrolene cost how much?

 

 

Definition

$909/year or $2.51 per day.

 

(certainly less than Tim's dream date on this slide)

 

Timmmmmaaaaaayyyyyyyy!!!!!

Term

Current concepts in M.H. (AKA: freakishly long True or false card)

 

1) Muscle rigidity may not be present in MH

 

2) Increased ETCO2 is an early sign

 

 

3) With proper treatment M.H. will not reoccur

 

4) Temperature increase is an early sign

 

5) MH may occur at any given point during an anesthetic

Definition

1) True

 

2) True

 

3) False

 

4) False

 

5) True

Term
How did they do testing for most of MH?
Definition

On poor little piggies with a ryanodine mutation.

 

 

I hear dantrolene injected bacon is delicious.

Term

How do we test for MH in humans to confirm diagnosis? 

 

What are the pros and cons of this testing?

Definition
  • Halothane/caffeine contracture test using muscle biopsy (vastus lateralis)- Gold Standard
  • $> 5,000 usually covered by insurance
  • Must go to center (there are 5 in U.S.)
  • Many false positives
  • Genetics looking for mutation of RYR-1 receptor hits only 30% positive so far.
Term
 A patient tests positive for the caffeine/halothane contracture test.  Now what?
Definition

Encouraged to be genetically tested.

 

If mutation known to be causative for MH is identified it is possible to determine MH susceptibility in other family members by examining the RYR-1 gene for that mutation.

 

Those with the defect are considered high risk for MH, however those who test negative can not be considered negative for MH.

Term

1) The RYR-1 gene is big or small?

 

2) How long to sequence it?

 

3) How many mutations are known?

 

4) Do all mutations cause M.H.?

Definition

1) Huge (per gayle)

 

2) 3 months

 

3) 80 mutations

 

4) no

Term
What other diagnosis do you have to rule out along with MH?
Definition
  • thyroid storm
  • Pheochromocytoma
  • Sepsis
  • Drug induced hyperthermia
    • Neuroleptic malignant syndrome
    • Serotonin syndrome
  • Iatrogenic hyperthermia
  • hypothalmic or brainstem injury
Term

What is the Emergency 24/7 Phone number for MH?

 

 

 

Definition
1-800-MH-HYPER
Term

You have a patient that is high risk for MH.

 

What do you do?

Definition
  • Avoid MH triggers (hey ya think?)
  • Anti anxiet medications
  • Change soda lime and breathing circuit
    • Remove vaporizers
    • flush machine with 10L O2 for at least 20 minutes OR 10 minutes if the fresh gas hose is also changed
  • Meticulous monitoring
  • Cooling blanket
  • MH stuff/ cart near by
  • Cold fluids (at least 3 liters)
Term

Pain perception is dependent on specialized ____________ that function as ______________

detecting the stimulus and then transducing and conducting it into the _____________.

Definition

1) neurons

 

2) receptors

 

3) Central Nervous system

Term
The sensation of pain can be classified as:
Definition

Either protopathic or epicritic. 

 

Protopathic can be futher subdivided into fast and slow pain

Term

What are the main points regarding Epicritic Pain/sensation?

 

I mean, If I were trying to annoy my wife with my newfound knowledge what would I likely tell her about epicritic pain?

Definition
  • Considered Non-noxious
  • Includes:
    • Light touch (A-β)
    • pressures (A-β)
    • proprioception (A-γ)
    • temperature discrimination (A-δ)
  • Receptors that conduct epicritic sensations have low thresholds and these stimuli are usually conducted by large myelinated nerve fibers (See above: alpha beta/alpha gamma)
Term
What type of fibers conduct protopathic pain?
Definition
Lightly mylenated alpha delta  or unmyelinated C nerve fibers.
Term

True or false:

 

Protopathic pain is considered noxious and receptors have a low threshold

Definition

False: high threshold

 

protopathic pain is considered noxious however

Term

We know that protopathic pain can be further divided into fast and slow pain. 

 

Describe Fast Pain:

 

Describe Slow pain:

Definition

Fast Pain: Short, localized stabbing sensations that match the stimulis (ex: pin prick or surgical skin incision)  The pain begins with stimulis and stops when stimulis is removed

 

Slow pain:  Throbbing, burning, or aching sensation that is poorly localized and less specific.

Pain continues long after simulis is removed.

Term

How is fast pain conducted?

 

 

How is slow pain conducted?

Definition

Fast: Alpha Delta fibers (lightly myelinated) at a conduction velocity of 12-30 m/s.

 

 

Slow: Via the unmyelinated C nerve fibers with conduction velocities of .5-2m/s.

Term

In 1968 Margo McCaffery went down in nursing infamy because she declared in a bellowing voice

this:

Definition
Pain is whatever the experiencing person says it is, existing whenever he says it does
Term
What term is used to describe only the neural events in response to trauma or noxious stimuli?
Definition
Nociception
Term

All nociception produces pain but not all pain results from nociception.

 

What the hell does that mean?

Definition
One can experience pain without noxious stimuli
Term

Acute pain is primarily due to what?

 

What are the 3 types of acute pain?

Definition

nociception.

 

Superficial, Deep somatic, Visceral

Term
Describe superficial pain
Definition
Nociception arises from the skin, SQ tissue, mucous membrane and is well localized, sharp, pricking, throbbing or burning sensations
Term
Describe Deep Somatic pain
Definition
Arises from muscles, tendons, joints or bones and is usually described as a dull aching quality and is less well localized
Term
Describe Visceral Pain
Definition

Is usually d/t disease or abnormal function of an internal organ or covering (ie: parietal pleura, pericardium or peritoneum, dura) 

 

Visceral pain can be true or deferred

Term

Chronic pain my be d/t nociception but also has other factors that often play a major role.

 

What are they?

Definition
Psychological and Behavioral factors
Term

There are 3 types of pain receptors.

 

What are they?

Definition

1) Mechanical Receptors

 

2) mechanothermal

 

3) Polynodal pain receptors

Term
These types of pain fibers are carried on the alpha-delta fibers:
Definition
Mechanical and mechanothermal receptors
Term

What do polynodal receptors respond to?

 

How do they conduct their impulses?

Definition

Mechanical, thermal, and chemical stimuli.

 

Conduct their impulses by the way of unmyelinated C Fibers.

Term
What chemicals are capable of activating the polynodal receptors?
Definition
acetylcholine, bradykinin, histamine, prostaglandins, and potassium ions
Term

True or False:

 

Pain receptors are highly adaptable which is important as a protective mechanism

Definition

False

 

Pain receptors do not adapt- which is an important protective mechanism

Term
The ONSET of ishemic pain is related to what?
Definition

Tissues rate of metabolism

 

ie: muscle ishemia can be felt in 15-20 seconds

 

Skin- 20-30 minutes

Term

Fill in the blanks (FROM HELL!! Hahha haha ah)

 

1) Pain signals from the periphery are carried via ____________________ (rapid conducting) and the ________________________ (slow conducting)

 

2) These Afferent fibers have their bodies in the ____________ ganglia and end in the __________.

 

3) In the dorsal horn they synapse with the ___________ neuron and __________ which may synapse with sympathetic neurons and ____________ neurons.

 

 

Definition

 1) Myelinated alpha delta fibers, Unmyelinated C Fibers

 

2) Dorsal root,  Dorsal Horn

 

3) second order, interneurons,  ventral horn motor

 

Term
As they enter the spinal chord the myelinated fibers and unmyelinated fibers tend to do different things.  What do they do?
Definition

Myelinated tend to migrate medially

 

Unmyelinated small fibers become more lateral.

Term

Your first order neurons like your Alpha delta or C fibers will synapse sometimes with ________ neurons then on to ____________ neurons in the dorsal horn of the spinal tract.

 

Then via the aforementioned neurons the signal crosses over to the ____________ tract then travels to the thalmus. 

 

So why is this interesting?

Definition

Interneurons

 

2nd order neurons

 

spinothalmic

 

Interesting because pain in the Right side of the body is then interpreted by the left side of the brain.  (and vice versa)

Term

Pain fibers can ascend or descend 1-3 spinal chord segments via this tract before synapsing with the second order neurons in the gray matter of the ipsilateral (same side) dorsal horn. 

 

Why is this important to us in anesthesia?

Definition

Lissauer tract

 

OR

 

Posterior Funiculus

 

Important: because this is why we overshoot with epidurals- in case pain travels via this tract.

Term
How is spinal chord grey matter divided
Definition
By Rexed into 10 lamina
Term
Tell me about the first 6 Rexed Lamina in the Spinal chord grey matter.
Definition
The first 6 receive all afferent neural activity and represent the PRINCIPLE SITE OF PAIN MODULATION. 
Term

A-Delta fibers synapse with cells in which lamina primarily?

 

And to a lesser extent?

 

C- Fibers

Definition

Lamina I and V

 

Lesser Extent: II, III, IV, V

Term

C-Fibers synapse with cells in which lamina primarily?

 

To a lesser extent?

Definition

Lamina I, II

 

Lesser extent: V

Term
Which Lamina is the superstar among anesthesia professionals- EVERYONE KNOWS THIS BABY!
Definition

Rexed Lamina II, AKA- Substantia gelatinosa

 

Has Mu receptors that are important for opioid action!

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