1. Anesthesia in Cerebral Palsy
Dr abdollahi
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5. Cerebral Palsy
‧Non-progressive disorder of motion and posture. ‧CP is a result of an injury to the developing brain during the antenatal, perinatal, or postnatal period. ‧Clinical manifestation relate to the area affected. ‧CP is the leading cause of childhood motor disability in developed country. ‧Such disabilities include cognitive impairment, sensory loss, seizures, communication and behavioral disturbances.
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6. علائم فلج مغزی
1-سفتی عضلات یا اسپاستی سيتی 2-حرکات غير طبيعی 3-اشكال در مهارتهای حرکتی درشت از قبيل راه رفتن یا دویدن 4-اشكال در مهارتهای حرکتی ظریف از قبيل نوشتن یا باز و بسته کردن دکمه های لباس 5-اشكال در مهارتهای ادراکی وحسی
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7. علائم فلج مغزی از یك فرد به فرد دیگر متفاوت است و با گذشت زمان ممكن است تغيير ننماید. بعضی از افراد مبتلا به فلج مغزی ممكن است به بيماریهای دیگر از قبيل تشنج، آسيب ذهنی اختلال یادگيری و تأخير رشدی نيز مبتلا باشند. اگر یك فرد مبتلا به فلج مغزی با گذشت زمان مشكلات او بيشتر شود، ممكن است این مشكلات چيز دیگری غير از ضایعه فلج مغزی او باشد.
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8. علائم اوليه فلج مغزی معمولاً قبل از 3 سالگی ظاهر می شوند
علائم اوليه فلج مغزی معمولاً قبل از 3 سالگی ظاهر می شوند. نوزاد مبتلا به فلج مغزی اغلب در مقایسه با کودکان عادی کندتر به مراحل رشدی خویش از قبيل غلتيدن، نشستن، چهار پا رفتن، لبخند زدن و ... دست پيدا می کنند.
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9. The cause of cerebral palsy remains unclear; however, intrapartum asphyxia, which was originally thought to be the major etiology of the disease, may be responsible for only 10% of the cases. Perioperative infections and low birth weight may play a much more important role.
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10. Etiology of Cerebral Palsy
Premature： ‧Periventricular hemorrhage  Periventricular leucomalacia ‧In spastic diplegia type Term baby： ‧Antenatal infection ‧Thyroid disease ‧Neuronal migration disorder Postnatal causes： ‧Meningitis, viral encephalitis, hydrocephalus, trauma, etc.
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11. Cerebral palsy is a nonprogressive motor impairment arising from lesions in the brain that occurred during the early stages of development—in utero (75%), at birth (10%), and soon after birth (15%)
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12. Classification for Cerebral Palsy
Spastic type：(70%)
Diplegia、Hemiplegia、Quadriplegia
Dyskinetic type： (21%)
Dystonia、Athetosis、Chorea
Ataxic type： (10%)
Intention tremor and head tremor (cerebellum)
Mixed type： (10%)
An impairment in the ability to control movements, characterized by spasmodic or repetitive motions or lack of coordination.
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13. تقسيم بندی فلج مغزی
تقسيم بندی فلج مغزی بر اساس تعداد اندامهای درگیر 1-کوادری پلژی : هر چهار اندام کودک درگير است. 2- دای پلژی : هر چهار اندام کودک درگير است اما درگيری پاها (اندام تحتانی) شدیدتر از دستهاست. 3-همی پلژی : یك طرف بدن درگير است معمولاً دست بيشتر از پا درگير است. 4-ترای پلژی : سه اندام درگير است معمولاً دو دست و یك پا. 5- منوپلژی : فقط یك عضو درگير است معمولاً یك دست.
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15. تقسيم بندی فلج مغزی بر اساس اختلال حرکتی
1- اسپاستيك : عضلات کودك اسپاستيك و سفت می باشد و در مقابل کشش بشدت مقاومت می کنند. این عضلات هنگامی که بكار گرفته می شوند بيش از اندازه فعال می شوند و حرکات زمختی را ایجاد می کنند. ناشی ازآسیب قشر مغزبوده و شایعترین فرم CP است. در حالت طبيعی عضلات بصورت جفت کار می کنند برای مثال وقتی یك گروه منقبض می شود گروه مخالف شل می شوند تا امكان ایجاد حرکت آزادانه را در راستای مورد نظر فراهم سازند. اما در عضلات استپاستيك هر گروه عضلانی بطور همزمان منقبض می شوند و حرکت را متوقف می سازند، که به این حالت انقباض همزمان گفته می شود.
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16. 2- آتتوئيد یا دیسکینیتیک : آتتوئيد عبارتست از اشكال در کنترل و هماهنگی حرکات ( 20%) کودکان مبتلا به فلج مغزی نوع آتتوئيد حرکات پيچشی غير ارادی و مداوم دارند. این افراد معمولاً مشكلات گفتاری نيز دارند. این ضایعه در اثر آسيب به هسته های قاعده ای مغز بوجود می اید. در این حالت وقتی بچه میخواهد کار خاصی را انجام دهد حرکات وی بیشتر میشود. مثلا در موقع راه رفتن یا وقتی میخواهد چیزی را بگیرد یا وقتی میخواهد حرف بزند این حرکات غیر ارادی شدت میگیرند.
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17. 3-آتاکسيك : فلج مغزی نوع آتاکسيك نادرترین نوع فلج مغزی است
3-آتاکسيك : فلج مغزی نوع آتاکسيك نادرترین نوع فلج مغزی است. افرادی که دچار فلج مغزی نوع آتاکسيك می باشند دچار یك آشفتگی و نقص در حس تعادل و حس عمقی (مخچه )می باشند. توان عضلانی این افراد پایين می باشد. عضلات آنها شل است و به حالت تلوتلو خوردن راه می روند و اندامهای فوقانی آنها در حالت راه رفتن بی ثبات می باشد.
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18. Although the neurologic deficit in cerebral palsy is nonprogressive, the secondary orthopedic consequences of the disease lead these patients to multiple surgical procedures.
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19. Normal skeletal developmental requires stress from the musculature to attain their proper shape and size. Without these stresses or with abnormal stresses as in cerebral palsy, various angular joint deformities and gracile (thin) shafts and abnormal articular joints develop.
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20. Orthopedic surgeries often involve loosening of tight muscles (hip adductor and iliopsoas release), releasing fixed joints, straightening abnormal twists (derotational osteotomy of the femur), rhizotomies to reduce spasm, and spinal surgery to correct kyphoscoliosis.
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21. Pre-operative assessment
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22. Gastro-esophageal reflux： Esophageal dysmobility、LES abnormal、 Salivary drooling： Impaired swallowing or tongue thrust and poor head control  Drooling  Tx：Anticholinergics MalnutritionFailure to thrive： Poor chewing and swallowing pre-operative nutrition support is needed. Electrolyte imbalance & Associated anemia
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23. Respiratory Problems
Pulmonary aspiration from reflux Recurrent respiratory infections Chronic lung disease Pre-operative physiotherapy、antibiotics、 bronchodilators may be required. Scoliosis： Cardiopulmonary compromise Others： Dental caries、loose teeth、temporomandibular joint dysfunction、tongue thrusting  oral bite & overjet may be needed.
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24. Epilepsy
‧Common in spastic hemiplegia
‧Tonic-clonic seizures
‧Complex-partial seizures
Normal anticonvulsant therapy should be continued up to and including the day of surgery.
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25. Visual deficits
Visual abnormalities： ‧40% of children with CP ‧Prematurity (1) Retinopathy of prematurityvisual impairment (2) Oculomotor problemsStrabismusAmblyopia (3) Visual field defect (4) Cortical blindness
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26. Behavioral & Communication Problems
Intellectual disability ‧2/3 children with CP ‧Learning problemsCommunication concern Attention deficit disorders ‧In higher functioning children ‧Self-injurious behaviors Depression and emotion problems ‧Common adolescent problems
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27. Premedication Sedatives to reduce anxiety and spasm during induction
Antacids
Local anesthetic cream at puncture site
Anticonvulsant Carbamazepine and sodium valproate
Antispasmodics Benzodiazepine、Baclofen to reduce muscle tone Clonidine、Botulinum neurotoxin
Anticholinergics Atropine (hyperthermia)、
Antidepressant
TCA、MAOI
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28. Anaesthesia in CP
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29. Peri-operative management
Have primary carers during induction Vascular access may be difficult Airway maintenance Anti-emetics Careful positioning Drug responses may vary Latex allergy has been reported Intra-operative hypothermia Standard monitoring
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30. Airway maintenance
Excessive secretions, A concern or a history of gastro-esophageal reflux Tracheal tube size selection should be based on their age as this usually provides the most appropriate fit.
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31. Drug responses
Resistance to non-depolarising muscle relaxants Reduced MAC relative to normal controls Most anaesthetic agents are anticonvulsants
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32. Resistance to vecuronium in patients with cerebral palsy.
Patients with upper motor neuron disease are resistant to NDMR.
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33. Children with CP and severe mental retardation may require lower concentration of inhalational anaesthetics than healthy children.
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34. Cerebral palsy patients have significant gastroesophageal reflux and poor laryngeal reflexes. In most cases, surgical procedures on cerebral palsy patients require general anesthesia with tracheal intubation, even if also accompanied by regional anesthesia to reduce the need for systemic anesthetics and to provide postoperative analgesia.
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35. Postoperative epidural analgesia with local anesthetic alone eliminates the potential complications of narcotics, and permits continued dosing with diazepam to relieve spasms. Regional anesthesia also may shorten emergence from general anesthesia, which can be prolonged because of inherent cerebral damage and the effects of antiseizure medications.
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36. Postoperative pulmonary complications are common owing to multiple causes, including aspiration, poor respiratory effort, and thoracic compliance. After major surgical procedures, cerebral palsy patients should be observed in a monitored setting for several hours.
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37. Post-operative management
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38. Emergence from anaesthesia may be delayed
Hypothermia Residual volatile anaesthetic agents
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39. Postoperative chest Physiotherapy
Drooling Poor cough Recurrent respiratory infections Impaired clearance of secretions
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40. Irritability on emergence from anaesthesia is common
Pain Urinary retention Unfamiliar environment
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41. Children with CP are prone to constipation
Reduced mobility Reduced fluid intake Undiagnosed gut mobility problems
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42. پيش آگهی های فلج مغزی
تحقيقات مختلف نشان داده است در صورتی که به مشكلات نورولوژیك (عصبی) افراد با مشكلات جسمی بطور صحيح و به موقع توجه شود، بسياری از آنها می توانند به یك زندگی تقریباً طبيعی دست یابند و از آن لذت ببرند.
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43. ACQUIRED IMMUNODEFICIENCY SYNDROME
DR ABDOLLAHI
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46. AIDS was first described in 1981 in the United States
AIDS was first described in 1981 in the United States. HIV and the AIDS pandemic pose a major threat to global health. It is estimated that more than 40 million people worldwide are infected with HIV, which is thought to have caused more than 25 million deaths to date.
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47. The infection continues to spread apace, the most rapid increases being observed in Southern and Central Africa and in South Asia. The predominant mode of HIV transmission is heterosexual sex, and women represent a high proportion of new infections, including in developed countries.
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48. HIV “Human Immunodeficiency Syndrome”
A specific type of virus (a retrovirus)
HIV invades the helper T cells to replicate itself.
No Cure

49. Increasing numbers of patients presenting for surgery are HIV seropositive or have AIDS. Anesthesiologists should be familiar with this disease and be aware of the impact of HIV on anesthesia. An understanding of the pathogenesis of HIV and awareness of the possible drug interactions occurring with HIV therapy may help to guide the choice of anesthetic techniques.
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50. The possibility of nosocomial transmission of HIV highlights the need for anesthesiologists to enforce rigorous infection control policies to protect themselves, other health workers, and their patients. Antiretroviral therapy decreases the rate of disease progression, but there is no cure available nor is a vaccine likely in the foreseeable future.
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51. HIV belongs to the family of Retroviridae and the genus Lentiviridae
HIV belongs to the family of Retroviridae and the genus Lentiviridae. Members of this genus are cytopathic (cell damaging), have long latent periods and run a chronic course. When cases of AIDS first appeared, its pathogenesis was frustratingly elusive because the disease does not appear immediately upon infection with HIV. There is a variable period during which the patient remains healthy but is viremic.
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53. Transmission HIV does not survive well in the environment.
HIV is found in varying concentrations or amounts in blood, semen, vaginal fluid, breast milk, saliva, and tears.
There have been rare occurrences of transmission between family members in households: usually resulting from contact between skin or mucous membranes and infected blood.

54. Signs and Symptoms
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56. Four Stages of HIV

57. Stage 1 - Primary
Short, flu-like illness - occurs one to six weeks after infection
no symptoms at all.
Infected person can infect other people.

58. Stage 2 - Asymptomatic Lasts for an average of ten years
This stage is free from symptoms
There may be swollen glands
The level of HIV in the blood drops to very low levels
HIV antibodies are detectable in the blood

59. Stage 3 - Symptomatic The symptoms are mild
The immune system deteriorates
Emergence of opportunistic infections and cancers

60. Stage 4 - HIV  AIDS The immune system weakens
The illnesses become more severe leading to an AIDS diagnosis

61. PCP (previously Pneumocystis carinii) does not usually occur until the CD4 count is less than 200 cells/mL. Breathlessness, night sweats, and weight loss are frequent complaints.
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62. Examination of the chest may be unremarkable
Examination of the chest may be unremarkable. Complications include respiratory failure, pneumothorax, and chronic pulmonary disease. Cavitary lung disease can be due to pyogenic bacterial lung abscess, pulmonary TB, fungal infections, and Nocardia spp. Kaposi's sarcoma and lymphoma can also affect the lung.
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63. Kaposi's sarcoma
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64. Adenopathy can lead to tracheobronchial obstruction or compression of the great vessels. Endobronchial Kaposi's sarcoma may cause massive hemoptysis. HIV directly affects the lungs, causing a destructive pulmonary syndrome similar to emphysema
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65. Neurologic disease, ranging from AIDS dementia to infectious and neoplastic involvement, is common.
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66. Cardiac involvement in the course of HIV is common, but often clinically silent. Aggressive generalized vascular disease, including cardiac and cerebral, may occur as a complication of antiretroviral therapy. When patients exhibit unexplained hypotension, adrenal insufficiency should be considered as this may occur with advanced HIV infection.
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67. Testing Options for HIV

68. Diagnosis
With the advent of highly active antiretroviral therapy (HAART), the prognosis for those infected with HIV is dramatically improved. It is important that the stigma attached to HIV infection is combated to enable routine testing.
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69. The standard test is an enzyme-linked immunosorbent assay (ELIsA), which usually becomes positive with the increase in antibodies to HIV 4 to 8 weeks after infection. During this initial window period, there is a high viral load and patients are more infectious. Confirmation of infection may be with a Western blot test or by measurement of HIV viral load in the blood.
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70. Lung-function tests show reduced lung volumes with decreased compliance and diminished diffusing capacity for carbon monoxide. Oxygen saturation measurements, or PaO2, on exercise can be more helpful than lung function tests.
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71. If PCP is suspected, fiberoptic bronchoscopy and bronchoalveolar lavage should be performed.
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72. Disseminated TB is a potential cause of severe respiratory failure, and respiratory secretions should be examined routinely for acid-fast bacilli in AIDS patients with pulmonary infiltrates.
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73. Up to 50% of patients with HIV have abnormal echocardiographic findings at some point in their disease. Approximately 25% have pericardial effusions, Myocarditis. Ventricular dilatation and cardiac dysfunction may result.
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74. With PI therapy, glucose intolerance and disorders of lipid metabolism are common. Random cortisol and tests of adrenal stimulation may reveal absolute and relative adrenal insufficiency.
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75. Treatment Options

76. Antiretroviral Drugs Nucleoside Reverse Transcriptase inhibitors
AZT (Zidovudine)
Non-Nucleoside Transcriptase inhibitors
Viramune (Nevirapine)
Protease inhibitors
Norvir (Ritonavir)

77. Treatment
Numerous side effects and drug interactions complicate such regimens and decrease compliance. Patients may acquire drug hypersensitivity reactions, resulting in fever, hypotension, and acute interstitial pneumonitis with respiratory failure.
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78. Concurrent use of zidovudine and corticosteroids may result in severe myopathy and respiratory muscle dysfunction. In addition, reports have documented several cases of respiratory failure related to HAART initiation and immune reconstitution resulting in a paradoxical worsening of Pneumocystis pneumonia.
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79. Of particular importance to anesthesiologists is that patients receiving HAART are subject to long-term metabolic complications, including lipid abnormalities and glucose intolerance, which may result in the development of diabetes, coronary artery, and cerebrovascular disease.
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80. Antiretroviral Drugs: Administration Tips and Side Effects
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82. Respiratory support and supplementary oxygen are invariably required
Respiratory support and supplementary oxygen are invariably required. Continuous positive airway pressure has, in some instances, obviated the need for positive pressure ventilation. The prognosis in patients who require mechanical ventilation despite adjunctive corticosteroid treatment is poor, and the use of PEEP can result in pneumothorax.
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83. Management of Anesthesia (Intraoperative )
Universal precautions for the prevention of transmission of blood-borne viruses were recommended in 1987 by the CDC. These precautions recommend that every patient be regarded as potentially infected with a blood-borne virus. Following an accident with high-risk body fluid, such as a (hollow) needlestick injury, postexposure prophylaxis is recommended for health workers.
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84. This should commence as soon as possible after the injury, ideally within 1 to 2 hours, but can be considered up to 1 to 2 weeks after the injury. Very high risk exposures may be treated beyond this time with a view to modifying rather than preventing infection. A recommended postexposure prophylaxis regimen for a duration of 4 weeks is zidovudine 250 mg every 12 hours, lamivudine 150 mg every 12 hours, indinavir 800 mg every 8 hours. The high rate of toxicity and noncompliance may necessitate other regimens
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85. Focal neurologic lesions may increase intracerebral pressure precluding neuraxial anesthesia. Spinal cord involvement, peripheral neuropathy, and myopathy may occur with cytomegalovirus or HIV infection itself.
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86. Suxamethonium may be hazardous in this setting
Suxamethonium may be hazardous in this setting. HIV infection is associated with autonomic neuropathy, and this can manifest as hemodynamic instability during anesthesia or in the ICU. Invasive hemodynamic monitoring may be helpful for severe autonomic neuropathy. Steroid supplementation may decrease hemodynamic instability and should be considered for unexplained hypotension.
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87. HIV infection does not increase the risk of postprocedural complications, including death, up to 30 days post-procedure. Thus, surgical intervention should not be limited because of HIV status and concern for subsequent complications. However, during anesthesia, tachycardia is more frequently seen in HIV-seropositive patients, and, postoperatively, high fever, anemia, and tachycardia are more frequent.
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88. Several studies indicate that general anesthesia and opiates may have a negative effect on immune function. Although this immunosuppressive effect is probably of little clinical importance in healthy individuals, the implications for the HIV- infected patient are unknown. Immunosuppression resulting from general anesthetics occurs within 15 minutes of induction and may persist for as long as 3 to 11 days.
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89. Postoperative immunosuppression may last longer in inherently immunosuppressed patients and may predispose to the development of postoperative infections or facilitate tumor growth or metastasis.
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90. HIV and AIDS are increasing in women of child-bearing age
HIV and AIDS are increasing in women of child-bearing age. In the ACTG-076 study, zidovudine monotherapy was shown dramatically to reduce the incidence of vertical transmission of HIV from 25.5% to 8.3%. However, zidovudine monotherapy has limited long-term benefit as HIV resistance develops rapidly. Therefore, in pregnancy, combination therapy is thought to be preferable. There are limited data on the use of PIs in pregnancy.
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