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What should be done prior to an elective surgery for a patient with history of TIA?
-must have an adequate medical evaluation, usually a noninvasive flow or imaging study
-document neurodeficits
When is a carotid endarterectomy indicated ?
When imaging studies show ulcerative plaque greater than 60% occlusion

-symptomatic patients only have to have stenosis >50% to be a candidate for sx
During the perioperative period how is HTN treated for a patient with a TIA?
-BP is maintained at or slightly higher (150-160mmHg) than normal d/t rightward shift in cerebral autoregulation

-avoid vasopressors to maintain BP

-use vasodilators or adrenergic blockade during intense stimulation and emergence
What happens to cerebral autoregulation in patient with HTN?
there is a rightward shift. meaning that CBF is more pressure dependent at low "normal" arterial pressures
What is the normal autoregulation of CBF?
Constant CBF between MAP 60-180mmHg
When should a pt with TIA have BP lowered?
When:
SBP>220
DBP>120
MAP>130
Where should neuromusclular blockade be monitored on a patient with a paralyzed extremity?
on a nonparalyzed extremity
Is it safe to give Sch to a patient with a recent stroke?
no, should be avoided for patient with recent hx of stroke
What 3 factors should preoperative evaluation of a patient with a seizure disorder consist of?
1. cause of seizure
2. type of seizure
3. medications patient is taking to treat the seizure
What are the primary priorities in dealing with a seizure perioperatively?
1. maintain open airway
2. adequate oxygenation
Medications to treat periop seizure?
Pentothal 50-100mg
phenytoin 500-1000mg slowly
Diazepam 5-10mg
midazolam 1-5mg
If a patient is on an AED drug what is the recommendation for administration of drug perioperatively?
1. ideally continued perioperatively to maintain therapeutic levels
2. most AEDs have significant half life so a delayed or missed dose won't hurt
What anesthetic agents should be avoided in patients with seizure disorder?
1. Ketamine (increase activity)
2. Brevital (decreases seizure threshold)
WHat is the metabolic consideration for patients taking AEDs?
Enzyme induction should be expected
-increased dose requirement and frequecy for IV anesthetics and NDMR
Dilantin drug regimen will have what effect on NDMRs?
Increase resistance to NDMR
What does loss of Dopamine in PD due to activity of the GABA nuclei in the basal ganglia?
-GABA activity increases inhibiting thalamus and brain stem nuclei

Thalamic inhibition suppress the motor system in the cortex leading to dyskinesia, rigidity, postural instability and resting tremor
What classes of medications are given to treat PD?
-Anticholinergic
-MAOIs
-Antiviral drugs
-Dopaminergic agents
-Catechol methyltransferase inhibitors
What is the most effective drug treatment for PD?
Levodopa with decarboxylase inhibitor, prevents the peripheral breakdown of drug and increase its duration
What drug can be given IV or Subq for rapid rescue thepay for sever motor fluctuationons for PD?
Apomorphine (dopamine agonist)
What drugs may not be given with MAOIs?
1. sympathomimmetics
2. meperidine
3. ketamine
4. epinephrine
5. pancuronium
What is subthalamic stimulation?
1. Treatment for PD
2. decreases need for medications
what is deep brain electrical stimulation for PD?
1. Used to treat the effect of the tremor by stimulation of the thalamus

2. electrode implanted into brain and placement of impulse generator near clavicle

What procedure did deep brain thalamic stimulation replace?
Thalamotomy
What med is good for premedication and intraoperative sedation for patient's with tremor r/t PD?
Benadryl
HOTN should be treated with what type of vasopressor in patient with PD?
Direct-acting, ie phenylephrine
What is the prognosis of cardiac stability in PD patient?
Cardiac irritability producing arryhtmias

-avoid halothane, ketamine and LA with epi
What is the intergrity of the GI system with patients who have PD?
1. excessive salavation
2. dysphagia
3. esophageal dysfunction (risk for aspiration)
what are the pathologic hallmarks of AD?
1. neurofibrillary tangles that contain the phosphorylated microtubular protein tau
2. neuritic plaques composed of Beta-amyloid.
What drugs are used in the treatment of AD?
1. cholinesterase inhibitors
2. psychopharmacologic agents
What will cholinesterase inhibitors patients with AD are on preop cause periop?
1. increase depolarizing muscle relaxant blockade
2. increase levels of Ach
3. inhibit pseudocholinestease activity
What is the recommended anticholinergic to use if need when patient has AD? y?
Glycopyyrolate, does not cross BBB
What is MS?
inflammation and demyelination in the brain and spinal cord

-acute phase has exacerabtion and remission d/t healing
-chronic has less remissions and less healing of demyelinated fibers
What do symptoms of MS depend on?
Site of injury in the brain and SC

1. optic tract- visual problems
2. oculomotor path- nystagmus
3. spinal cord- limb weakness and parestesias
4. brainstem- diplopia, trigeminal neuralgia, cardiac dysrhymias, and autonomic dysfunction, alterations in ventilation
what is the diagnostic tool for MS?
MRI, provides direct evidence of location of demyelinated plaques in the CNS
What can increase in temperature cause in patients with MS?
Temp increase of 0.5C can block impulse conduction in demyelinated fibers
What factors may increase risk of perioperative exacerbation of MS other than anesthesia?
-Infection
-Emotional stress
-Hyperpryrexia
what warning should be given to a patient with MS preoperatively?
that surgery and anesthesia could produce a relapse despite a wellmanaged anesthetic
What is the risk of regional anesthesia in the MS patient?
- exacerbation of the disease
- demyelinated areas of SC are more sensitive to LA causing neurotoxicity
Can epidural analgesia be used in patient with MS?
Yes, given in lower concentrations it is fine
Baclofen, med given to relax spastic muscles, has what interaction with NDMR?
causes an increased sensitivity to NDMR
What can symptoms of autonomic dysfunction cause when volatile anesthetics are given?
exagerrated hypotensive response
What volatile anesthetics have rarely cause production of seizure activity?
Iso and Des
-d/t dose-dependent depression of EEG activity
What effect do volatile anesthetics have on patients with PD?
Autonomic dysfunction may cause exaggerated responses in BP d/t volatile anesthetics
Are the volatile anesthetics safe to use in patients with PD? ketamine?
All 3 volatile anesthetics have no reports of adverse responses

Ketamin has been used without difficulty in PD patients, observe for tachycardia and HRN
PD patients being treated with dopamine agonists are at risk for what syndrome?
neuroleptic malignant syndrome
What effect do tricyclic antidepressants have on anesthetics?
- increased anesthetic requirement r/t enhanced brain catecholamine activity

- potentiation of atropine and sclopolamine
What drugs should be avoided with tricyclic antidepressants?
-ketamine
-pancuronium
-meperidine
-epi containing La
what is neuroleptic malignant syndrome?
-rare complication of antipsychotic therapy
-occurs hours to weeks after drugs given
-presents similiar to MH
what two drugs precipitate NMS?
metoclopramide and meperidine
Patho of NMS?
-blockade of dopamine in the basal ganglia, hypothalamus, and impairment of thermoregulation
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