Term
| Collection of nuclei found on both sides of the thalamus and associated with many functions which include motor control, emotion, cognitive learning. Subdivisions: Putnum, caudate nucleus, pallidus, subthalmic nucleaus, substantia nigra. |
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Definition
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Term
| Neurodegenerative disease occuring in the substantia nigra resulting in the loss of dopaminergic receptors (inhibitory) and unopposed acetylcholine |
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Definition
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Term
| System of neurons that coordinate motor movement |
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Definition
| Extrapyramidal motor system |
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Term
| With Parkinson's disease, (enhancing/depleting) dopamine results in the extrapyramidal system's excitatory neurotransmitter, acetylcholine being (inhibited/uninhibited)? (choose one) |
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Definition
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Term
True or False: Age is the MOST important risk factor in Parkinson's?
What are some risk factors? |
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Definition
True
(Mostly effects people between ages of 50-70 years. Also linked to exposure to chemicals/drugs (MPTP and MPPP) to destroy dopaminergic cells or neurons or is heavily associated with a familial genetic disorder) |
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Term
| What does TRAP stand for? |
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Definition
Classic "triad" of Parkinson's Disease
- Tremors-movements that worsen with REST and improves with voluntary motor movement
- Rigidity-proximals muscles of neck first
- Akinesia-difficulty initiating and maintaining motion. Loss of normal arm swing, failure to rotate head,...slowness to execute movement is "bradykinesia"
- Postural instability-offten associated with injury (portal to OR)
- Emotional disturbances are also common-insomnia, depression, memory loss, dementia, hallucinations
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Term
| What are the treatment goals for Parkinson's Disease? |
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Definition
- Increase amount of dopamine in substantia nigra (consider BBB) or inhibit the acetylcholine
- ANTIcholinergic drugs
- Levodopa
- Symptom management
- Surgical management-DBS anesthetic implications (ARTICLE)
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Term
| Parkinson's Disease Drugs |
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Definition
Increase Dopamine
MAOI
Oral Dopamine
COMT Inhibitors
Decrease Acetylcholine
Anticholinergics |
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Term
| What is the normal percentage of Dopamine concentrated in the basal ganglia (caudate nucleus and putamen)? What percentage with Parkinson's? |
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Definition
| 80%; decreases to approx. 10% of normal |
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Term
| True or False: Dopamine readily crosses the BBB? |
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Definition
| False; dopamine does NOT cross the BBB; a precursor to dopamine is levodopa---> Levodopa crosses the BBB and is converted to dopamine |
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Term
| Levodopa crosses the BBB and is converted to dopamine by what enzyme? |
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Definition
| dopa decarboxylase enzyme; restoring the supply of dopamine |
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Term
| Levodopa is usually adminstered with what type of drug in order to maximize the of levodopa entering the brain? |
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Definition
| Peripheral decarboxylase inhibitor; this inhibits the conversion of levodopa to dopamine in the periphery (where dopamine does NOT cross the BBB) |
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Term
| Levodopa-->dopamine circulating outside the brain can produce...? |
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Definition
HTN and Tachycardia
(decarboxylase inhibitors reduce these SE) |
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Term
| Levodopa has a (short/extended) 1/2 life? (choose one) |
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Definition
| Short; 1-3 hours and requires FREQUENT dosing orally (i.e. in the OR) |
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Term
| True or False: Levodopa can be discontinued abruptly? |
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Definition
| False; not advised-rapid exacerbation of symptoms and neuroleptic malignant-like syndrome |
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Term
| What are the EARLY and LATE side effects of levodopa? |
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Definition
Early: Nausea and hypotension, salivation
Later: Involuntary movements, tics, grimacing and rocking of arms/legs/trunk MOST common side effects of chronic therapy (50% of patients within 1-4 mos) |
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Term
| True or False: Antidopaminergics are used to treat Parkinson's Disease? |
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Definition
| False; can antagonize levodopa and worsen disease |
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Term
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Definition
Butyrophenones=haldol,droperidol
Phenothiazines=compazine, phenergan
Prokinetics=reglan |
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Term
| MAOI (exaggerate/blunt) levodopa? (choose one) |
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Definition
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Term
| Anticholinergics (improve/worsen) the symptoms of involuntary movements due to dopamine? (choose one) |
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Definition
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Term
COMT
(peripheral decarboxylase inhibitor) |
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Definition
| Catechol-O-methyl transferase |
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Term
| Blocking the COMT enzyme will PREVENT breakdown of levodopa and increase the plasma concentration by what percent? |
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Definition
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Term
| Explain how anticholinergics work for the treatment of Parkinson's Disease |
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Definition
| Blunt the effect of the excitatory neurotransmitter acetylcholine; correcting the imbalance between dopamine and acetylcholine (MUST CROSS BBB) |
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Term
| Glycopyrolate-Cross the BBB? |
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Definition
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Term
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Definition
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Term
| Occurs particularly in the elderly when given anticholinergic; CNS dysfunction: Confusion, hallucinations, memory disturbances, sedation and the mydriasis can produce blurred vision |
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Definition
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Term
| Thought to decrease the reuptake of dopamine or promote dopamine release at the nerve terminals (Tx:Antiviral...Parkinson's) |
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Definition
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Term
| What drug can be used to increase availability of acetylcholine in the treatment of anticholinergic syndrome? |
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Definition
| Neostigmine-blocks the breakdown of acetylcholine by inhibiting acetylcholinesterase |
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Term
| Anesthetic Management of Parkson's |
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Definition
1. Medications should be continued up to the day of surgery (NO abrupt withdrawal); consider dosing during OR
2. AVOID antidopaminergics (phenergan, compazine, haldol...etc.). Zofran CAN be used as well as Benadryl
3. Premedication and nausea control. Anticholinergics (atropine) and benadryl may be useful for exacerbation of symptoms, PLUS Benadryl is VERY useful sedative/antiemetic for these pt.'s
4. Induction agents for pt.'s on Levodopa may lead to hypo- or hypertension
5. Hypotension should be treated with DIRECT acting agent (Epinephrine, norepinephrine). Ephedrine has IN-Direct effects.
6. Autonomic instability-consider A-LINE
7. Small incidence of hyperkalemia with SUCCS. |
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Term
| Autosomal dominant disease where the caudate nucleus of the basal ganglia is destroyed or dysfunctional that leads to not enough acetylcholine and too much dopamine |
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Definition
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Term
| Dopamine is moderated in the caudate nucleus by...? |
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Definition
| GABA; inhibits dopamine; reduced in Huntington's Chorea |
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Term
| True or False: Huntington's Chorea is diagnosed primarily in the elderly? |
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Definition
| False; this is a 'young person's disease' most people presenting in 30-40's |
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Term
| Symptoms seen with Hungtington's Chorea? |
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Definition
| Jerking, uncontrolled random movements (Chorea); BEFORE the movement begins the pt. often exhibits mood changes/depression/RAGE ISSUES...ETOH, compulsive behaviors, pharyngeal muscle control loss (ASPIRATION) and death 12-20 yrs. after dx. |
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Term
| True or False: Using Succs in a Huntington's Chorea pt. may cause prolonged paralysis? |
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Definition
| True; correlation between a reduction in plasma cholinesterase (Succs has similar structure to ACTH and is broken down by cholinesterase) |
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Term
| What type of medication is used to control movements and emotional disturbances in Huntington's Chorea? |
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Definition
| Antidopaminergics (like Haldol...with butyrophenone or phenothiazines) |
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Term
| True or False: Huntington's Chorea pts are NOT sensitive to NDMRs? |
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Definition
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Term
| General category of conditions in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures |
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Definition
| Dystonia; Thought to be a defect in the production or release of GABA; causes can be hereditary, trauma induced, psychiatric or drug induced (antidopaminergic drugs). |
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Term
| Dystonia that involves intense contractions of the neck and facial muscles |
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Definition
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Term
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Definition
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Term
| Anesthetic implications for dystonias (spasmotic torticollis) |
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Definition
| Change in vertebral structures and anatomy, may require awake fiberoptic intubation; Positioning issues; induction allergic responses, rhizotomy cautions |
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Term
| If a dystonic reaction occurs on induction...? |
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Definition
| NDMRs will relax the muscle structures |
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Term
| If a dystonic reaction occurs due to medication administration...? |
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Definition
| Considered an ALLERGY and Benadryl 25-50mg IV is choice drug to reverse torticollis |
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Term
| With a rhizotomy at C1-C3, there is a potential for loss of? |
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Definition
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Term
| Neurodegeneration and progressive loss (increases with age; patients >70 yo) of gray matter. Progressive impairment of memory, judgment, decision making, and emotional lability |
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Definition
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Term
| Alzheimer disease accounts for what percentage of all dementia in the U.S.? |
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Definition
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Term
| Treatment of Alzheimer disease targets what? |
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Definition
| Slowing of the disease; NO treatment has been found |
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Term
| Some challenges with Alzheimer patients... |
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Definition
1. Consent issues-only if they are able to demonstrate a cognitive understanding of the procedure and its implications. It is important to reassure pt. and allow as much involvement as possible
2. Uncooperative-Regional anesthetics requires pt. cooperation. GENERAL anesthesia is often used.
3. Central acting drugs (most of what we use to induce general anesthesia) can produce PROLONGED and UNPREDICTABLE effects in the Alzheimer pt. Premedicate w/ small doses "use less and give more". Delerium can be associated with anticholinergics that cross BBB (atropine, scopolamine), so AVOID. Use glycopyrolate (does NOT cross BBB) |
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Term
| Reversible demyelination at random sites in the brain and spinal cord. Chronic inflammation produces scarring and permanent effects. (?autoimmune that is initiated by a viral infection). Effects primarily females (2:1) between the ages of 20-40 yrs. Unpredictable with periods of 'attacks' and 'remissions' (until remissions become infrequent). Symptoms depend on group of neurons effected (sensory, visual, motor) |
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Definition
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Term
| True or False: Keeping a pt. with MS warm is priority in the OR? |
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Definition
| False; Temperature is an important factor in conduction across the demyelinated neurons. Increases in body temperature EXACERBATE the symptoms (decreasing transmission). |
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Term
| True or False: If an MS pt. has a relapse, elective surgeries can proceed? |
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Definition
| False; elective surgeries should be avoided if an MS pt. has relapsed |
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Term
| When having a pt. with MS consent...the consent should reflect what? |
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Definition
| That the anesthetic and surgery may WORSEN the disease and symptoms |
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Term
| True or False: Spinal anesthesia is the preferred method with MS pt.'s? |
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Definition
| False; spinals have been shown to exacerbate the disease whereas, regional techniques and epidural blocks do NOT |
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Term
| The MS pt.'s cardiovascular system may be _______ due to autonomic dysfunction? |
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Definition
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Term
| Succinylcholine should be AVOIDED in MS pt.'s...why? |
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Definition
| If the patient has paralysis, parasthesia, or is bed/chair bound due to risk of hyperkalemia (UP REGULATION) |
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Term
| An OR temperature increase of ______ degree(s) Celsius may cause complete ______ ______!!!! AVOID INCREASING BODY TEMPERATURE. |
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Definition
0.5 degrees Celsius
Conduction Block |
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Term
| Caused by enterovirus that initially infects the reticuloendothelial system (mononuclear phagocyte system). |
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Definition
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Term
| The polio virus usually enters the CNS and prefers to target (motor/sensory) neurons in the brainstem and anterior horn of the spinal cord? (choose one) |
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Definition
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Term
| S+S of Post Polio Sequelae |
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Definition
| Fatigue, skeletal muscle weakness, joint pain, cold intolerance, dysphagia, and sleep and breating problems. The RAS system may be impacted |
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Term
| The RAS system may be impacted in post-polio pt.'s, this is impacted by their (sensitivity/insensitivity) to sedatives and anesthetics? (choose one) |
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Definition
| Sensitivity to sedatives and anesthetics which may cause delayed waking in post-polio pts |
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Term
| True or False: Keeping post-polio pt.'s WARM in the OR is priority? |
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Definition
| True; HIGHLY sensitive to cold |
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Term
| Besides post op shivering, what other post operative issue impacts post-polio patients in assessing appropriateness of outpatient surgery? |
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Definition
| Post op PAIN also seems to be increased due to poliovirus damage to endogenous opioid secreting cells in the brain and spinal cord |
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Term
| Neurodegenerative disease that effects the MOTOR neurons (50-60 yo). Variations follow familial patterns. RAPIDLY progressive that starts on 1 side of the body but eventually impacts both sides. RESPIRATORY muscles are effected leading to death. Heart usually unaffected. |
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Definition
Amyotrophic Lateral Sclerosis (ALS)
Lou Gehrig's Disease |
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Term
| Anesthetic Implications for ALS |
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Definition
1. Progressive motor weakness to RESPIRATORY-judicious respiratory care
2. NO SUCCS-often have limited movement; bedbound; W/C
3. NDMR sensitivity |
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Term
| Would you extubate an ALS pt. deep v. awake? |
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Definition
| Awake-pt. may remain on a ventilator-VERY DIFFICULT to wean |
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Term
| Would you do a regional technique on an ALS pt.? |
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Definition
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Term
| True or False: A detailed preoperative functional assessment should be performed to confirm postoperative return of function in ALS (all neurodegenerative diseases) pts.? |
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Definition
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Term
| Common immune reaction against myelin typically follows after a viral/GI infection. Progressive rise in motor function and autonomic instability. Associated with neoplastic/HIV. Some respond to plasmaphoresis. |
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Definition
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Term
| Can be acquired, familial or congenital and is a set of symptoms that may be included in many other disease processes and vary based on the nerves involved. |
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Definition
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Term
| Common concerns (2) for anesthetists concerning autonomic dysfunction pts.? |
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Definition
| Hypotension and HTN; Based on their symptoms, pt.'s will be on several different drug classes (sympathomimetic, beta-blockers, etc.) |
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Term
| Pt. with autonomic dysfunction experiences hypotension...pt. will not do well with significant drops in BP, how do you treat it? |
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Definition
DIRECT acting drugs
(Epi, Norepi...)
VERY SENSITIVE to vasopressors, so "start low and go high" |
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Term
| Pearl concerning autonomic dysfunction |
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Definition
| Pts. with diabetes develop autonomic dysfunction |
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Term
| Most spinal cord transections injuries are due to? |
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Definition
| Fractures and dislocation of the vertebrae; thoracic spine=compression or over flexion; cervical spine=over extension |
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Term
| A SCT injury above C3-C5 requires? |
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Definition
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Term
| Transections above______ result in quadraplegia and above _______ results in paraplegia. |
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Definition
T-1
L-4
MOST common injuries are C5-6 and T12-L1 |
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Term
| The period of spinal shock occurs for _______ following the injury. After this time, the reflexes begin to return. |
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Definition
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Term
| Common features of spinal shock? |
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Definition
Hypotension and Bradycardia
(the bradycardia can be distinguishing factor spinal vs. hemorrhagic shock) |
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Term
| Anesthetic Concerns-Acute spinal transection |
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Definition
1. Prevent further damage-stabilize cervical spine; secure airway techniques (awake fiberoptic SAFEST)
2. High dose methylprednisone (30mg/kg over 1 hr., gtts. 5.4mg/kg/h for 23 hrs.)
3. Hypotension and bradycardia-spinal shock=VASOPRESSORS and some fluid
4. Induction agents that don't drop BP (Etomidate/Ketamine)
5. Succs can safely be administered within 24 hours. of injury. |
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Term
| Explain why succs should NOT be used in acute SCT 24 hours after the injury |
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Definition
| Due to denervation, the acetylcholine receptors proliferate (UP regulate) both at the neuromuscular junction and outside the synaptic cleft (organs). Produces HUGE release of potassium. |
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Term
| What is the dose for the suggested corticosteroid therapy in acute spinal cord injuries? |
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Definition
Methylprednisone: 30mg/kg over 1 hour
5.4mg/kg/h for the next 23 hours
(there is some association with sepsis, pneumonia, and prolonged hospitalization-lack of evidence to support corticosteroid therapy outcomes) |
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Term
| Occurs in spinal injuries ABOVE T-5; rarely seen if injury is below T-10; cutaneous/visceral stimulation below cord injury sends impulses up thru spinal cord but cannot reach the brain past the level of injury. A reflex arc activates the uninhibited sympathetic portion of the autonomic nervous system resulting in increased SVR, HTN, bradycardia, vasodilation above level of injury |
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Definition
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Term
| Once the reflex arc is activated by an impulse taveling through and injured spinal cord, the parasympathetic system is unable to inhibit the sympathetic response, why? |
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Definition
| The parasympathetic system response is unable to extend from the brain down to the level of injury. The result is increased in SVR and HTN |
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Term
| What receptors are activated as a result of autonomic hyper-reflexia's HTN and increased SVR symptoms? |
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Definition
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Term
| With autonomic hyper-reflexia, the baroreceptors detect the elevated pressure and reflexively decrease heart rate and vasodilate vessels (above/below) the injury? |
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Definition
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Term
| Steps to Autonomic Hyper-Reflexia |
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Definition
T-6 (or above) injury
1. Cutaneous/visceral stimulation
2. SANS stimulation-->HTN; "goose flesh", pallor, muscle spasms
3. Increased SVR-->Baroreceptor response signaled
4. Bradycardia and vasodilation ABOVE level of injury |
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Term
| Symptoms for (above/below) cord injury: Flushing, sweating, HA and nasal stuffiness in autonomic hyper-reflexia? (choose one) |
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Definition
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Term
| Symptoms for (above/below) cord injury: Pallor, pilomotor erection, muscle contraction/spasm in autonomic hyper-reflexia? (choose one) |
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Definition
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Term
| Transient, synchronous discharge of neurons in brain; common and can occur at any age; many are related to treatable causes (hypoglycemia, hyponatremia, drug toxicity, hypoxia, fever, IICP); 10% of the population has experienced. Symptoms vary depending on area of brain affected |
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Definition
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Term
| True or False: Most practitioners prefer to use a multi-drug approach when treating seizure disorders? |
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Definition
| False; (1) drug preference; Seizure drugs are guided by the desired effect and TOXICITY levels-->neurologic toxic effects resulting in sedation, depression, ataxia, diplopia, hepatic failure, aplastic anemia, hyponatremia... |
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Term
| Anesthesia Concerns-Seizures |
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Definition
Many drug side effects
Do the drugs stimulate the brain activity or lower the seizure threshold?
Drug levels?
Recent seizure?
Are they well controlled?
Sedate? |
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Term
| Continuous seizure of two or more without a recovery phase (life threatening) |
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Definition
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Term
| Treatement for status epilepticus includes...? |
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Definition
- IV acess-->IV benzodiazapine (versed or valium)
- Airway management, support respirations,
- Support cardiovascular system
- Find cause (r/o hypoglycemia-dangerous because extends brain injury boundaries)
- Propofol or pentothal will temporarily HALT the seizure to access airway
- Subsequent problems (metabolic acidosis, hyperthermia)
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Term
| Why are Succs and NDMR not recommended in status epilepticus? |
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Definition
| Just blocks motor response, but neuronal activity of seizure still occuring |
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Term
| What drugs INCREASE the seizure threshold? |
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Definition
- benzodiazapines (versed and valium)
- propofol
- pentothal
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Term
| What drugs DECREASE seizure threshold, making a seizure 'more likely' to occur? |
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Definition
- etomidate
- demerol (metabolite)
- atracurium and cisatricurium (NDMR-metabolite)
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