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6901 > 6901 endo > Flashcards

6901 endo Flashcards

1
Q

Examples of peptide hormones?

A

insulin, ADH, angiotensin, erythropoeitin, GH

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2
Q

How are peptides released in to the blood stream?

A

exocytosis of granules they’re stored in and released in to ECF

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3
Q

Some examples of amine hormones?

A

catecholamines (epi, serotonin, norepi, dopa) and thyroxine

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4
Q

Lipid hormones are derived from where?

A

cholesterol

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5
Q

Are lipid hormones stored in granules? What are they bound to? What effect does that have?

A

no; bound to plasma proteins which delays their metabolism

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6
Q

Examples of lipid hormones?

A

aldosterone, estrogen, progesterone, adrenalcorticoids-cortisol, aldosterone

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7
Q

How are lipids transported?

A

simple diffusion

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8
Q

Where are hormone receptors located?

A

on the surface of the cell or inside the cell

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9
Q

Hormone receptors display a high affinity for what?

A

right hormone

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10
Q

What directs the hormone to the correct target organ?

A

location receptor

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11
Q

How do peptide and protein hormones exert their effects?

A

interact by activating the receptor site on the cell surface, and it generates a 2nd receptor (often cAMP)

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12
Q

3 hormones which use cAMP (there are others)?

A

vasopressin, TSH, parathyroid hormone

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13
Q

What are 2 other 2nd messengers?

A

Ca, cyclic GMP

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14
Q

How do lipid hormones exert their effects?

A

they attract specific hormones in various locations and since they’re lypophillic they diffuse in to the cell

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15
Q

Hormone receptor number is inversely related to?

A

concentration of circulating hormone

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16
Q

Hormone secretion and suppression are caused by what three things?

A

biorhythms (circadian), neural controls (pain, smell, taste), feedback

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17
Q

Homeostasis is controlled by what 2 systems?

A

endocrine and nervous

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18
Q

6 functions endocrine system regulates?

A

behavior, growth, metabolism, fluid status, development, reproduction

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19
Q

The 8 endocrine glands are?

A

pancreas, thyroid, parathyroid, adrenal glands, placenta, testes, ovaries, pituitary gland

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20
Q

This gland secretes hormones that effect all other endocrine glands?

A

pituitary

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21
Q

4 functions of pituitary gland?

A

homeostatic, developmental, metabolic, and reproductive

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22
Q

How big is the pituitary gland?

A

small, size of pea, 500 g

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23
Q

Where is the pituitary gland located?

A

base of brain in sella turcica

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24
Q

What structure connects the pituitary gland to the hypothalamus?

A

hypophyseal stalk

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25
Q

The pituitary gland is between the ______ _______ and the _____ ________

A

optic chiasm, optic tracts

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26
Q

What regulates hormone release from the anterior and posterior pituitary?

A

hypothalamus

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27
Q

Another name for the anterior pituitary and the posterior pituitary?

A

adenohypophysis; neurohypophysis

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28
Q

Why is the posterior pituitary unique?

A

it receives synthesized hormones from the hypothalamus

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29
Q

6 hormones released from anterior pituitary?

A

GH, ACTH, thryotropin (TSH), FSH, LH, prolactin

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30
Q

How does GH act?

A

similarly to insulin-metabolic and endocrine ftns thruout the body- skeletal muscle development, growth, carb, and protein metabolism regulation

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31
Q

What does ACTH do?

A

stimulates release of cortisol and androgens from adrenal glands

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32
Q

What does thyrotropin do?

A

growth and metabolism of thyroid gland and stimulates thyroid gland to release TH/thyroid hormones

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33
Q

What does FSH do and where is it secreted?

A

stimulates estrogen production and ovarian follicle development in females and is secreted from ovaries and spermatogenesis in males

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34
Q

What does LH do?

A

stimulates progesterone production and ovulation and corpeus luteum in females and testosterone production and spermatogenesis in males (??)

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35
Q

What does prolactin do?

A

stimulates lactation from mammary glands, mammary gland development, inhibits synthesis and secretion of LH and FSH, this hormone is markedly increased during pregnancy

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36
Q

What % of the pituitary gland is the anterior lobe?

A

80%

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37
Q

5 causes of hyposecretion from the anterior pituitary gland?

A

large nonfunctional pituitary tumors, postpartum shock/Shehan syndrome, irradiation, trauma, hypophysectomy (surgical removal of pituitary gland)

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38
Q

What is panhypopituitarism?

A

lack of pituitary hormones rather than just lack of 1 and it’s more common than lack of 1

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39
Q

What 3 hormones are commonly effected with panhypopituitarism?

A

TSH, ACTH, gonadotropic hormones

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40
Q

5 manifestations of congenital anterior hypopituitarism?

A

micropenis, midline defects, optic atrophy, hypoglycemia, poor growth

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41
Q

A decrease in what hormone leads to decrease in thyroid function?

A

TSH

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42
Q

What hormone would decrease glucocorticoid production by the adrenal cortex?

A

ACTH

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43
Q

A decrease in what hormone would cause a depressed sexual development and reproductive function?

A

gonadotropic hormone secretion

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44
Q

Hormone deficiency symptoms: hypoglycemia, vomiting, malaise?

A

cortisol

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45
Q

Hormone deficiency symptoms: fatigue, constipation, cold intolerance, bradycardia?

A

thyroxine

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46
Q

Hormone deficiency symptoms: delayed puberty, amenorrhea, micropenis?

A

sex steroids

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47
Q

Hormone deficiency symptoms: short stature, hypoglycemia?

A

growth hormone

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48
Q

Hormone deficiency symptoms: polyuria, polydyspsia, hypernatremia, lethargy, dehydration?

A

ADH

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49
Q

A treatment of hypopituitarism? What 2 meds may be required afterwards?

A

surgical removal- steroids, thyroid hormone replacement

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50
Q

What do you have to watch out for after surgical removal of the pituitary and what’s the treatment for that?

A

DI- vasopressin

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51
Q

Usual approach for removal of pituitary? Whats the other approach?

A

transphenoidal/nasal; transcranial

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52
Q

Why is a precordial particularly important for surgical pituitary removal?

A

to detect venous air embolism bc in sitting position (low ETCO2)

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53
Q

What gas do you need to avoid for removal of ant pituitary? Why?

A

N20; surgeon injects air and N20 is more soluble than nitrogen so it diffuses in more quickly and can expand a closed space

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54
Q

Do you want muscle relaxation for surgical removal of pituitary?

A

yes

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55
Q

Why do you need a quick, smooth emergence for surgical removal of pituitary? And what can help facilitate that?

A

allow for neuro checks; give lido to prevent bucking

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56
Q

Why would BP increase during removal of pituitary?

A

surgeon injects local with epi

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57
Q

What should you prepare the pt for post operatively if having pituitary removed?

A

will have nasal packing and feel congested/pressure

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58
Q

Potential complications of transphenoidal pit removal and which ones are not common?

A

meningitis, CSF leak, ischemic stroke, visual loss; not common: epistaxis, symptomatic hyponatremia, transient DI, cranial nerve damage

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59
Q

Most pituitary tumors are?

A

hypersecreting pituitary adenomas

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60
Q

What is a common hormonal abnormality associated with pituitary adenomas?

A

excessive prolactin secretion with lacturia

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61
Q

The most common hypsersecretion pituitary tumors secrete what 3 hormones?

A

prolactin, ACTH, GH

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62
Q

ACTH excess is called?

A

Cushing’s disease

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63
Q

Prolactin secreting tumors produce what 3 effects?

A

infertility, amenorrhea in women, and decreased libido in men

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64
Q

What med can you treat decreased libido with?

A

bromocriptine (dopamine agonist)

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65
Q

Other name for GH?

A

somatotropin

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66
Q

Releasing and inhibiting hormones from where regulate GH activity throughout the day?

A

hypothalamus

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67
Q

How do the levels of GH change throughout one’s lifetime?

A

rate of secretion is increased in childhood, followed by an even greater rise in adolescence. levels plateau in adulthood and drop in old age

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68
Q

What increases amt of GH secreted?

A

stress- OR, hypoglycemia, exercise, deep sleep

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69
Q

How is GH regulated?

A
  • feedback
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70
Q

How does GH increase blood glucose levels?

A

decreases the sensitivity of cells to insulin and inhibits glucose uptake in to the cells

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71
Q

T/F: Feedback can be initiated by the peripheral target cells to only the hypothalamus?

A

F: feedback can be initiated to the pituitary too

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72
Q

What is hypersecretion of GH usually caused by?

A

GH secreting pituitary adenoma

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73
Q

Hyposecretion of GH is called what? And what does that do to blood sugar?

A

dwarfism, hypoglycemia

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74
Q

If sustained hypersecretion of GH occurs after adolescence it is referred to as?

A

acromegaly

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75
Q

If GH secretion is elevated before adolescence it is called?

A

gigantism

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76
Q

What effects does acromegaly have on the bone, organs, lung volumes, and facial features?

A

bone gets thicker and larger, organs are enlarged (kidneys, spleen, heart, liver), lung volumes increase (increase VQ mismatch with increased extrathoracic obstruction), coarse facial features

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77
Q

Treatment of hypersecretion of GH?

A

removal of pituitary tumor

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78
Q

4 cardiac conditions associated with acromegaly?

A

CM, HTN, accelerated atherosclerosis, LVH

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79
Q

2 endocrine abnormalities from acromegaly?

A

glucose intolerance, DM

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80
Q

Some anesthetic considerations for pt w hypersecretion of GH?

A

may need to size ETT down by 1, may have difficult mask fit d/t enlarged facial features, may be difficult DL d/t macroglossia/ tissue overgrowth, extubate pt when fully alert, >60% pts have sleep apnea, monitor blood glucose and lytes, be careful w positioning bc have entrapment and neuropathies

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81
Q

Posterior pit gland secretes what 2 hormones?

A

ADH, oxytocin

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82
Q

increased serum osmolarity= __ ADH?

A

increased

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83
Q

This hormone stimulates milk ejection during lactation?

A

oxytocin

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84
Q

This hormone controls water reabsorption and excretion in the kidney

A

ADH

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85
Q

This hormone stimulates uterine smooth muscle contraction?

A

oxytocin

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86
Q

Derivatives of oxytocin are used for what 2 things in L&D?

A

inducing labor, decreasing postpartum bleeding

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87
Q

What receptor does ADH act on in renal collecting ducts?

A

V2

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88
Q

ADH is released at which mOsm/L value?

A

284

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89
Q

Normal mOsm/L?

A

285-290

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90
Q

2 things that stimulate ADH release?

A

10-20% decrease in plasma volume or blood pressure

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91
Q

ADH secretion increases with what 4 things?

A

pain, hemorrhage, emotional stress, nausea

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92
Q

Which organ increases ADH synthesis and release?

A

hypothalamus

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93
Q

Baroreceptors send signals via which nerves to the hypothalamus to tell the hypothalamus to increase ADH synthesis and release?

A

vagus, glossopharyngeal

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94
Q

DI hallmark symptoms?

A

polyuria, polydypsia

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95
Q

DI leads to dehydration and what type of Na balance?

A

hypernatremia

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96
Q

DI has what type of concentration of ADH?

A

low

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97
Q

Normal urine osm values? And what are they in DI?

A

500-800;

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98
Q

2 types of DI?

A

neurogenic-destruction of post pit where there is inadequate secretion of ADH and nephrogenic- inability of renal collecting duct receptors to respond to ADH

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99
Q

S/S DI?

A

hyperreflexia, weakness, lethargy, seizures, coma

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100
Q

The difference in the 2 types of DI is the response to desmopressin. In neurogenic, desmopressin does what? In nephrogenic desmopressin does what?

A

neurogenic: concentrates urine; nephrogenic: does not concentrate urine

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101
Q

DI after pituitary gland surgery is generally d/t reversible trauma to posterior pituitary and is ______?

A

transient

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102
Q

Treatment for DI short term and long term?

A

short term- vasopressin; long term- desmopressin

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103
Q

Is vasopressin admin before surgery necessary with partial DI?

A

usually not because ADH is released in response to surgery

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104
Q

What 3 parameters should be measured qh and in recovery for patients with DI?

A

UO, plasma osm, serum Na

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105
Q

What does treatment of complete DI target?

A

increasing receptor response to ADH

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106
Q

What type of fluids for DI unless serum osm reaches 290, then what?

A

isotonic; then hypotonic fluids

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107
Q

What happens in SIADH in the renal tubules when there is hypoosmolarity?

A

water is reabsorbed in renal tubules

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108
Q

Emergence may be slow/fast in SIADH pt?

A

slow

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109
Q

4 s/s of SIADH?

A

weight gain, increased skeletal muscle weakness, mental confusion, convulsions

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110
Q

4 drugs associated with increased ADH release?

A

tricyclic antidepressants, tegretol, diabanase, nicotine

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111
Q

6 causes of SIADH?

A

hypothyroidism, pulmonary neoplasia, head trauma or infection, intracranial tumors, posterior pituitary surgery, ADH secreting neoplasms (small cell carcinoma of the lung)

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112
Q

Treatment for mild SIADH and severe SIADH?

A

mild: fluid restriction (800 mL/day); severe w neuro s/s: hypertonic saline with lasix

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113
Q

Serum osmolarity in SIADH vs DI?

A

SIADH 290

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114
Q

Serum Na in SIADH vs DI?

A

SIADH 145

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115
Q

Gland that helps regulate Ca balance?

A

thyroid

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116
Q

Where is the thyroid gland located?

A

immediately below the larynx and on either side of and anterior to trachea

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117
Q

What does the thyroid gland need to produce the hormones?

A

iodide

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118
Q

Which 2 nerves are in intimate proximity to thyroid gland?

A

RLN, external motor of SLN

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119
Q

The thyroid gland is composed of follicles filled w what?

A

thyroglobulin, an iodinated protein that serves in thyroid hormone synthesis

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120
Q

What 3 hormones does the thyroid gland secrete?

A

T3, T4, calcitonin

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121
Q

Does the thyroid gland have much blood supply?

A

yes it has a very rich blood supply

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122
Q

Thyroxine/T4 is what % of thyroid hormone and is it potentn in the blood?

A

93% and it’s less potent in the blood

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123
Q

T3 is what % of thyroid hormone and is it potent in the blood?

A

7% and it’s more potent in the blood

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124
Q

Normal adult level of T3 and T4?

A

T3- 70-132; T4- 5-12

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125
Q

How is iodine absorbed in to the blood?

A

it’s reduced to iodide in the GI tract then absorbed in to the blood

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126
Q

How does iodide trapping occur?

A

when active transport carries iodide into the thyroid follicular cell

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127
Q

Where is iodide converted to oxidized iodine?

A

thyroid

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128
Q

Why does iodide need to be converted to oxidized iodine?

A

it is capable of combining w tyrosine residues of thyroglobulin

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129
Q

Normal quantities of thyroid hormone depend on?

A

exogenous iodine

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130
Q

Which T hormone (hormone) is converted to the other T hormone?

A

T4 is converted to T3 at the tissue sites

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131
Q

Which thyroid hormone primarily inhibits TRH and TSH in negative feedback?

A

T3

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132
Q

How do T3 and T4 have a direct effect on the heart?

A

+ inotropic and chromotropic, which may decrease the vascular tone and MAP, causing activation of renin aldosterone system , which increases the circulating blood volume and CO

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133
Q

This hormone stimulates every tissue in the body to produce proteins and increase the amt of O2 used by the cells?

A

thyroid

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134
Q

Peak age of Grave’s Disease?

A

40

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135
Q

Amiodarone is rich in what and therefore can cause what?

A

iodine; hypo or hyperthyroidism

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136
Q

TSH and T4 diagnosis for thyrotoxicosis?

A

decreased TSH, increased T4

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137
Q

Some etiologies of Grave’s disease?

A

benign follicular adenoma, iodine excess, thyroid hormone OD, goiter, thyroiditis, TSH secreting pituitary tumor, thyroid cancer

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138
Q

These drugs inhibit thyroid hormone synthesis?

A

methimazole, propylthiouracil, carbimazole

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139
Q

These drugs prevent thyroid hormone release?

A

K, sodium iodide

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140
Q

These drugs mask signs of over adrenergic activity in hyperthyroidism?

A

atenolol, propranolol

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141
Q

This destroys thyroid cell function?

A

radioactive iodine

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142
Q

What happens to hair, breasts, fingers, and extremities in hyperthyroidism?

A

fine straight hair, enlarged breasts, clubbing fingers, localized edema

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143
Q

Some preop anesthetic considerations for hyperthryoidism?

A

thyroid enlargement may cause tracheal deviation, awake fiberoptic intubation with LA may be necessary, blood volume is increased, peripheral resistance is increased, and pulse pressure is wide, ask ab hoarseness, cough, pressure in the neck, dyspnea

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144
Q

3 anesthetic drugs to avoid with hyperthyroidism?

A

ketamine, cisatracurium, atropine

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145
Q

Is there an increase in MAC with hyperthyroidism? Explain

A

no, but the increased CO and blood volume may increase the inhalational requirements

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146
Q

How should you intubate a pt in hyperthyroidism?

A

in deep level of anesthesia

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147
Q

How should one treat intraoperative hypotension in pt with hyperthyroidism?

A

w direct acting like phenylephrine bc the indirect acting can increase catecholamines

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148
Q

What 2 acid base symptoms stimulate SNS and should be avoided in those with hyperthyroidism?

A

hypercarbia, hypoxia

149
Q

Why do you have to position hyperthryoidism pts carefully?

A

decreased bone density and predisposition to osteoporosis

150
Q

What do you have to keep in mind regarding NMB in pts with hyperthyroidism?

A

usually don’t use them after induction unless surgeon requests them and there is an increased incidence of myopathies and myasthenia gravis in those w hyperthyroidism so titrate them carefully

151
Q

ETT with NIM monitoring is used for hyperthyroidism surgeries because?

A

to assess RLN

152
Q

ETT with NIM: red and blue electrodes should be where?

A

right on right, blue on left

153
Q

Most serious threat to hyperthyroidism pt undergoing surgery?

A

thyroid storm

154
Q

3 events that may precipitate thyroid storm?

A

trauma, surgery, labor & delivery

155
Q

Thyroid storm presentation is similar to what 4 things?

A

pheo, MH, light anesthesia, NMS

156
Q

Mortality rates of thyroid storm are as high as what?

A

30%

157
Q

3 s/s of thyroid storm during surgery?

A

fever > 38.5, HTN, afib, tachycardia

158
Q

Other s/s thyroid storm in awake pt?

A

agitation, confusion, tremor, N/V, CHF, shock/metabolic acidosis, abnormal LFTs

159
Q

Treatment for thyroid storm?

A

cooling (Tylenol), IV hydration with glucose containing fluids, beta blockers, K iodide (block release of T3, T4), antithyroid drugs (PTU or methimazole), glucocorticoids (cortisol), correct electrolyte and acid base balances

160
Q

3 post op complications w hyperthyroid pt?

A

RLN damage, hematoma, hypothyroidism

161
Q

S/s unilateral RLN damage? S/s bilateral RLN damage?

A

unilateral: hoarseness; bilateral: aphonia and stridor (reintubate)

162
Q

Hypoparathyroidism will occur how long after hyperthyroidism surgery?

A

24-72 h

163
Q

Which problem, MH or thyroid storm is more of a hypermetabolic state?

A

MH

164
Q

Differentiating s/s of MH versus thyroid storm?

A

MH is sudden unexplained rise in ETCO2, trismus, and RAPID temp rise; temp will usually rise later in thyrotoxicosis

165
Q

6 causes of hypothyroidism?

A

autoimmune mediated inflammation, iodine deficiency (lithium), medications, surgery for hyperthyroid, neck irradiation, radio iodide therapy

166
Q

Diagnosis of primary hypothyroidism versus secondary hypothyroidism?

A

primary: decreased T4 and or T3, increased TSH; secondary: decreased T4, T3, TSH

167
Q

95% of all hypothyroidism cases are?

A

Hashimoto thyroiditis

168
Q

Treatment of hypothyroidism involves replacement of which hormone?

A

T4

169
Q

Some unthought of s/s of hypthyroidism?

A

CHF, gastroparesis, hypoventilation, hyponatremia, poor mentation

170
Q

What happens to the hairline, tongue, and muscles in hypothryoidism?

A

receding hairline, thick tongue, muscle aches and weakness

171
Q

Late clinical manifestations of hypothyroidism?

A

bradycardia, wt gain, subnormal temp, decreased LOC, thickened skin, cardiac complications

172
Q

Careful eval of airway is needed for what 3 reasons in hypothyroidism pts?

A

enlarged thyroid gland, enlarged tongue, myexedematous infiltration of vocal cords

173
Q

What are 2 reasons that pts with severe hypothyroidism are at risk for problems during surgery?

A

myocardial ftn and baroreceptor ftn may be depressed

174
Q

Is MAC in hypothyroid pts affected?

A

no

175
Q

Why would RSI be good in hypothyroid pt?

A

increased risk of aspiration d/t slower gastric emptying

176
Q

A good medication for induction in hypothyroid pt?

A

ketamine

177
Q

Why is respiratory depression following administration of opioids a possibility w hypothyroid pts?

A

baroreceptor response to hypercarbia and hypoxia may be depressed; large tongue and goiter hypoxia and hypercarbia may be present

178
Q

What cardiac effects may be present in hypothyroid pt?

A

hypotension, myocardial depression, plasma volume may be reduced

179
Q

If hypothyroid pt is experiencing muscle weakness what do you need to keep in mind?

A

may be sensitive to nondepolarizers

180
Q

What medication may be necessary intraoperatively in hypothyroid pt d/t potential for adrenal insuffiency r/t stress?

A

cortisol

181
Q

Why may hypothyroid pt have delayed recovery/emergence?

A

hepatic metabolism and renal clearance of drugs may be slower and have prolonged effect

182
Q

Why may response to inotropic drugs in hypothyroid pt be diminished?

A

the # of beta receptors is decreased

183
Q

Myexedema coma may be precipitated by what?

A

surgery, usually in elderly pts

184
Q

Myexedemia is more common in what pts and what are 3 symptoms?

A

elderly; hyponatremia, hypothermia, hypoventilation

185
Q

Where are parathyroid glands located? And how many do most ppl have?

A

posterior surface of thyroid gland; 4 (some have 3 or 5)

186
Q

What is the blood supply to the parathyroid glands?

A

inferior thyroid arteries

187
Q

Parathyroid hormone is released from what in response to what?

A

chief cells in parathyroid gland in response to low serum ionized Ca

188
Q

PTH is also released in response to what 2 electrolyte abnormalities?

A

hyperphosphatemia, acute hypomagnesemia

189
Q

PTH does what to extracellular calcium and extracellular phosphate?

A

increases;decreases

190
Q

What would be a fairly common cause of parathyroid gland hypertrophy?

A

lactation and pregnancy which cause a sustained deficit in ionized Ca and therefore result in hypertrophy

191
Q

How does PTH increase Ca?

A

it acts on bone to mobilize Ca; osteoclasts stimulate rapid absorption of Ca from bone to ECF

192
Q

What does increased ECF Ca do to PTH?

A

decreased PTH release stimulating deposition of Ca

193
Q

3 ways in which PTH increases Ca?

A

increased decomposition of bone, releasing Ca, increased absorption of Ca from food by intestines, reabsorption of Ca from urine by kidneys

194
Q

This hormone is secreted from the thyroid in response to elevated ionized Ca?

A

calcitonin

195
Q

Which cells in the thyroid secrete calcitonin?

A

parafollicular/C cells

196
Q

How does PTH increase renal absorption of Ca?

A

PTH promotes the formation of an active form of vit D when plasma Ca levels are low by secreting an enzyme in the kidneys which increases intestinal absorption of Ca and phosphate

197
Q

Why does kidney disease or absence of PTH result in hyopcalcemia?

A

enzyme in kidneys is not formed and effect of vit D on Ca and phosphate regulation is lost

198
Q

Parathyroid dysfunction affects what 3 areas of the body?

A

bone, intestinal tract (absorption of Ca), kidney (formation of vit D, reabsorption of Ca, and increased excretion of phosphate)

199
Q

Hyperparathyroidism= ______calcemia

A

hyper

200
Q

S/s hyperca?

A

HTN, ventricular dysrhythmias, shortened QTI, impaired renal concentrating ability, renal failure, polyuria, polydipsia, ileus, N/V, muscle weakness, osteoporosis, mental status changes

201
Q

The enzyme vitamin D1 hydroxylase converts what to the active form 125 OH vit D? And at what level does this increase Ca absorption?

A

liver byproduct 25 hydroxy vit D; small intestine

202
Q

Normal Ca levels?

A

8.8-10.4

203
Q

90% of time parathyroidism is due to what?

A

adenoma

204
Q

Hyperparathyroidism is where PTH levels are high in spite of?

A

high serum Ca

205
Q

In hyperparathyroidism calcifications may be formed in which organs leading to dysfunction?

A

pancreas-pancreatitis, kidney- nephrolithiasis, polyuria, heart- bradyarythmias, BBB, heart block, stomach- peptic ulcer

206
Q

What type of anesthesia can removal of PT gland be performed under?

A

general or cervical plexus block with MAC

207
Q

Severe hypercalcemia (what value is that) is treated with what?

A

> 13-16; isotonic saline and loop diuretics

208
Q

Some anesthetic considerations for pts with hyperparathyroidism?

A

renal status (failure, stones, polyuria), avoid hypoventilation bc hyperventilation blows Ca away, may be sensitive to NMB, arrythmias respond to Ca channel blockers, prone to PONV, careful with positioning

209
Q

How does alkalosis lower Ca?

A

it shifts Ca to protein bound form and decreases serum levels of Ca

210
Q

Why would one have hypoparathyroidism?

A

inadequate secretion of PTH or peripheral resistance to its effect

211
Q

3 causes of hypoparathyroidism?

A

removal of PT tissue, radiation, chronic Mg deficiency (alcoholism)

212
Q

Why do ppl with hypoparathyroidism experience muscle spasms and tetany?

A

threshold of excitable membranes is lowered

213
Q

Post op parathyroidectomy- beware of what 2 things?

A

laryngospasm, resp distress d/t edema, bleeding, or bilat RLN damage

214
Q

Treatment for post op parathyroidectomy?

A

Ca Cl IV slow

215
Q

Is being unable to talk after a parathyroidectomy normal?

A

no-maybe bilat RLN damage and need to intubate

216
Q

How does insulin lower blood sugar?

A

insulin binds to a receptor on the cell, which activates protein cascades, and translocation of GLUT 4 transporter to the plasma membrane brings in an influx of glucose, which then leads to glycolysis and fatty acid synthesis

217
Q

What are islets of langerhans?

A

microscopic collections of cells scattered throughout the pancreas which produce hormones

218
Q

How do the hormones produced by the islets of langerhans take effect?

A

they are directly secreted in to the capillary blood vessels rather than entering the ducts

219
Q

What is the blood supply of the islet cells like?

A

abundant blood supply

220
Q

What % of beta cell ftn is lost in Type I DM before hyperglycemia occurs?

A

80-90%

221
Q

What is the short and sweet patho description of Type I DM?

A

glucose is presence in abundance but unable to reach the cells d/t lack of insulin

222
Q

Pathophysiology of Type II diabetes?

A

impaired insulin secretion, peripheral insulance resistance, excessive hepatic glucose production d/t environmental, genetic, lifestyle factors

223
Q

When blood glucose rises >?, glucose spills in to the urine?

A

180-200

224
Q

When insulin is deficient what does the liver do?

A

liver increases its glucose output so intracellularly glucose is low but extracellularly glucose is high

225
Q

Glucose starved cells use what for fuel?

A

fat and protein

226
Q

The increased breakdown of triglycerides to free fatty acids and glycerol contributes to what (in diabetic pts)?

A

atherosclerotic and angiopathic changes

227
Q

What becomes the main energy source in the diabetic pt?

A

fatty acids

228
Q

Why are increased fatty acids bad in the diabetic pt?

A

fatty acids are converted to ketone bodies in the liver, H concentration increases, and the ketone body acetone is excreted by the lungs, resulting in acetone breath

229
Q

What causes weight loss, weakness, and organ dysfunction in diabetic pt?

A

protein catabolism, free amino acids are converted in the liver into glucose

230
Q

What does A1C mean?

A

structural tissue proteins and hemoglobin become glycosolyated, which contributes to organ damage

231
Q

How much more likely is diabetic pt to have HTN than nondiabetic pt?

A

twice as likely

232
Q

A diabetic pt with sudden hypotension- you should think?

A

silent MI

233
Q

Risk of MI is __-__ times higher in diabetic that nondiabetic?

A

2-10

234
Q

Risk of stroke is how much larger in diabetic versus nondiabetic?

A

twice

235
Q

Risk of PVD is __ to ___ higher in diabetic versus nondiabetic?

A

5-10 x greater

236
Q

Autonomic neuropathy leads to dysfunction of vagus nerve resulting in?

A

orthostatic hypotension, tachycardia, dysrthymias

237
Q

Autonomic neuropathy does what to GI system?

A

risk for aspiration, slowed gastric emptying, reflux esophagitis

238
Q

What happens to the diabetic pt’s response to atropine and propranolol?

A

reduced response d/t autonomic neuropathy

239
Q

Some other complications of autonomic neuropathy?

A

lack of sweating, lack of hr variability, resting tachycardia, asymptomatic hypoglycemia

240
Q

Are diabetics with gastroparesis mask candidates?

A

no

241
Q

Why do you have to be careful with preop sedation and post op pain meds in diabetic pts?

A

impaired respiratory response to hypoxia

242
Q

4 labs necessary to eval kidney ftn in diabetic pt?

A

UA, BUN, creat, lytes

243
Q

Stiff joint syndrome is seen more with which type of diabetic pt?

A

Type I

244
Q

Test for stiff joint syndrome?

A

+ prayer sign

245
Q

What 2 parts of ortho system may be involved in stiff joint syndrome and make intubation difficult in diabetic pt?

A

TJ joint and C spine limited movement

246
Q

A1C

A

7

247
Q

Standard types of measurement of glucose before surgery?

A

venous plasma or serum

248
Q

Why might chronic hyperglycemia leave the pt dry?

A

it’s associated w osmotic diuresis

249
Q

What is a pt at risk for if they take metformin before surgery?

A

hypotension, renal hypoperfusion = lactic acidosis and accumulation in renal impairment, CHF, liver disease

250
Q

Metformin should be held how long before surgery?

A

> 48 hours

251
Q

What type of surgeries do you have to be cautious ab in pts with an insulin pump?

A

electrocautery and radiation

252
Q

How much dose 1 unit of insulin lower blood glucose?

A

40-50 mg/dL

253
Q

Beware of anaphylaxis with what drug in pts taking NPH or protamine zinc insulin?

A

protamine sulfate

254
Q

What causes hyperglycemia intraoperatively?

A

activation of SNS, catecholamine, cortisol, and GH secretion

255
Q

You can see LOC/seizures at blood glucose

A

50

256
Q

Some causes of hypoglycemia?

A

beta blockers, severe liver disease, toxins (ethanol), gastric bypass surgery, sepsis, insulin secreting tumor

257
Q

In a 70 kg pt, 15 mL of D50 raises the blood glucose concen by what?

A

30 mg/dL

258
Q

1 mL of D50 raises blood glucose concen by how much?

A

2 mg/dL

259
Q

DKA is usually in which type of diabetes?

A

I

260
Q

DKA usually develops over how long?

A

24 hours

261
Q

Triad for DKA?

A

hyperglycemia, acidosis, ketonemia

262
Q

In DKA blood sugar is usually > than what?

A

250

263
Q

6 precipitants of DKA?

A

critical illness, MI, trauma, CVA, burn, infection

264
Q

S/s DKA?

A

volume depletion (5-8 L), tachycardia, met acidosis, lyte depletion (hypokalemia), N/V, abdominal pain, fruity odor to the breath (ketones from lack of insulin), Kussamaul respirations, coma

265
Q

2 complications associated with DKA?

A

gangrene and ischemic lower extremity

266
Q

Treatment for DKA?

A

isotonic fluids, K, insulin

267
Q

Is mortality higher with DKA or HHS?

A

HHS

268
Q

Why is HHS life threatening?

A

it’s a hyperglycemic state that leads to diuresis and severe dehydration

269
Q

Glucose is usually > than what in HHS?

A

600

270
Q

S/s HHS?

A

hyperglycemia, polyuria, polydipsia, hypovolemia, hypotension, tachycardia, organ hypoperfusion, acidosis, risk of thrombus, hyperosmolality, seizures, coma

271
Q

Hypoosmolality > than mOsml induces dehydration of neurons?

A

360

272
Q

What does severe hyperglycemia do to Na?

A

produces false hyponatremia

273
Q

With each 100 mg/dL increase in blood sugar, plasma Na concentration lowers by?

A

1.6 mEq/L

274
Q

In HHS if plasma osmolarity is >320, what fluid should be given and until when?

A

large volumes 1000-1500 mL/h of 1/2 NS until osmolarity

275
Q

What are some hazards to rehydrating in elderly?

A

rehydrate slowly because they are prone to cerebral edema and CHF

276
Q

Difference in the pH of DKA vs HHS?

A

pH 7.3 in HHS

277
Q

Difference in serum osmolarity between DKA and HHS?

A

serum osmolarity is greater in HHS

278
Q

Difference in mental obtundation in DKA vs HHS?

A

mental obtundation is present in HHS but variable in DKA

279
Q

Difference in serum K with DKA vs HHS?

A

normal or slight increase in DKA; normal or lower in HHS

280
Q

Function of adrenal glands?

A

synthesize and store essential hormones

281
Q

Outer and inner part of adrenal gland?

A

outer= cortex; inner= medulla

282
Q

3 hormones secreted by adrenal cortex?

A

mineralcorticoids (aldosterone); glucocorticoids (cortisol); androgens (dehydroepiandrosterone)

283
Q

Hormone secreted by adrenal cortex which maintains and regulates immune and circulatory function and effects carbo, protein, and fatty acid metabolism?

A

glucocorticoids/cortisol

284
Q

This adrenal cortex hormone regulates ECF volume and K thru reabsorption of Na and secretion of K?

A

mineralcorticoids (aldosterone)

285
Q

4 times which produce an increase in aldosterone?

A

surgery, CHF, hypotension, hypovolemia

286
Q

4 things which stimulate release of aldosterone?

A

angiotensin II, ACTH, pituitary hormones, hyperkalemia

287
Q

What stimulates synthesis of cortisol?

A

ACTH

288
Q

These hormones enhance gluconeogenesis and inhibit peripheral glucose utilization?

A

glucocorticoids/cortisol

289
Q

Inner part of adrenal gland and the hormones it secretes?

A

adrenal medulla; norepi, epi, dopamine

290
Q

This catecholamine constitutes 80% of adrenal catecholamine output?

A

epi

291
Q

Because glucocorticoids are structurally related to aldosterone, they promote what?

A

Na retention and K excretion

292
Q

This hormone is responsible for vascular and smooth muscle response to catecholamines?

A

glucorticoids/cortisol

293
Q

Mechanism for regulating cortisol secretion?

A

ACTH, CRF

294
Q

Most potent regulator of ACTH?

A

cortisol

295
Q

4 things cortisol does?

A

gluconeogenesis, protein mobilization, fat mobilization, stabilizes lysosomes

296
Q

Cortisol had direct - feedback effect on what and inhibits release of what? then, the anterior pituitary decreases release of?

A

hypothalamus; CRH and CRF; ACTH

297
Q

Secretion of what 3 things follow circadian rhythms?

A

ACTH, cortisol, and CRH

298
Q

Daily production of cortisol is usually?

A

15-30 mg

299
Q

Increased aldosterone production, which is a dysfunction of the adrenal cortex, results in?

A

excess mineralocorticoid

300
Q

2 types of increased aldosterone production-primary and 2ndary- are caused by what?

A

primary: (Conn syndrome), from adrenal adenoma independent of stimulus; 2ndary: increased renin production

301
Q

3 s/s of increased aldosterone and treatment for it is?

A

HTN, ECF volume weakness; surgical removal of tumor-lap adrenalectomy

302
Q

Increased aldosterone causes what for the Na/K pump?

A

Increased Na/K exchange so a decrease in K and retention of Na

303
Q

A good drug to manage HTN for hyperaldosteronism?

A

Spironolactone (aldosterone antagonist)

304
Q

You should avoid what w the vent in a hyperaldosteronism pt?

A

hyperventilation bc it will lower the K further

305
Q

Why do you have to be careful with NMB in hyperaldosteronism pts?

A

hypokalemia may enhance the MR

306
Q

Overproduction of cortisol is what disease?

A

Cushing’s

307
Q

Causes of Cushing’s?

A

anterior pituitary or adrenal tumors

308
Q

Most common cause of Cushing’s?

A

exogenous administration of corticosteroids

309
Q

S/s Cushing’s?

A

central obesity with thin extremities, HTN, moon face, striae, thin, atrophic skin, muscle weakness, increased intravascular fluid volume, hypokalemia, fatiguability

310
Q

Anesthetic management for pt with Cushing’s?

A

lytes, Spironolactone, careful w positioning, conservate MR if muscle weakness present, increased risk of infection, thromboemboli are more common, need supplemental steroids

311
Q

Why are thromboemboli more common in Cushing’s pt?

A

HTN, obesity, increased Factor VIII, high hct

312
Q

Addison’s disease is deficiency in what 3 hormones?

A

adrenal androgens, glucocorticoids, mineralcorticoids

313
Q

2 causes of Addison’s disease?

A

TB, autoimmune diseases

314
Q

Primary cause of Addison’s? And what are some causes of that?

A

destruction of adrenal gland; congenital, infection, malignancy, trauma, HIV, adrenal hemorrhage

315
Q

2ndary cause of Addison’s?

A

decrease in ACTH

316
Q

Tertiary cause of Addison’s?

A

d/t exogenous admin of glucocorticoids and cortisone admin

317
Q

S/s Addison’s?

A

(cortisol def): fatigue, weakness, weight loss, abdominal pain, diarrhea, hypoglycemia; aldosterone def: volume depletion-orthostatic hypotension, hyponatremia, hyperkalemia, hyperpigmentation

318
Q

Treatment of Addison’s?

A

100 mg Hydrocortisone or Prednisone

319
Q

Which anesthetic drug can cause adrenal insufficiency and should avoided in those pts prone to adrenal insufficiency?

A

etomidate

320
Q

Benefits of steroid therapy are weighed down by some risks such as?

A

glucose intolerance, stress ulcers, impaired wound healing, immunosuppression

321
Q

What is acute adrenal crisis?

A

sudden onset of severe adrenal insufficiency

322
Q

How does acute adrenal crisis progress and what can cause it?

A

very rapidly and is life threatening; stress

323
Q

Main sign of acute adrenal crisis?

A

HD instability

324
Q

Have high suspicion of acute adrenal crisis if?

A

hx of autoimmune, exogenous steroid use, HD instability, hyperpigmentation

325
Q

Pheo is a catecholamine secreting tumor which consists of cells originating from?

A

embryonic neural crest (chromaffin tissue)

326
Q

Are pheos usually malignant and in both adrenal glands?

A

usually benign and in one adrenal gland

327
Q

4 s/s of pheo?

A

paroxysmal headache, sweating, HTN, palpitations

328
Q

First indication of pheo can be?

A

intraop HTN and tachycardia

329
Q

A pheo diagnosis is made w what and a false + can be caused by what?

A

urine metaneprhine level; coffee, tricyclics, phenoxybenzamines; another diagnostic test is a suppression test- clonidine will suppress catecholamines that are neurogenically controlled, but will not suppress catecholamines from pheo

330
Q

Should you give an alpha or beta blocker first in pheo pt?

A

alpha bc beta may cause dilation in skeletal muscles and worsen HTN

331
Q

Alpha blocker and dose for pheo?

A

Phenoxybenzamine 10 mg BID, increasing q 2-3 days by 10-20 mg for a max dose of 1mg/kg

332
Q

Beta blocker helps control what in pheo pt?

A

reflex tachycardia

333
Q

When is beta blocker added in pheo pt?

A

several days after initiation of alpha blocker; to avoid the possibility of unopposed alpha constriction resulting in severe HTN and ischemia

334
Q

5 preop treatment endpoints for pheo pt?

A

1) BP 24 hours; 2) presence of orthostatic hypotension (not

335
Q

3 beta blockers good for pheo?

A

propranolol (20-80); atenolol (12.5-25); metoprolol (25-50)

336
Q

Avoid what 5 drugs/actions in pheo pt intraop?

A

ephedrine, ketamine, hypoventilation (SNS stimulation); atracurium, MS (histamine)

337
Q

6 good drugs to give in pheo pt?

A

alpha blockers, beta blockers, MgSO4, nicardipine, nitroprusside and nitroglycerin

338
Q

Post of HTN in pheo pt may indicate?

A

another tumor

339
Q

Treatment for post op hypotension in pheo pt?

A

fluids are initial therapy, phenyl pushes and gtt, Norepi gtt

340
Q

One reason why hypotension is common in post op pheo pt- what type of blockade is persistent?

A

alpha blockade

341
Q

What is MEN?

A

overactivity of 2+ endocrine glands

342
Q

MEN 1 disorders and bold the most common occurring tumor?

A

pituitary adenoma, PARATHYROID HYPERPLASIA, pancreatic tumors

343
Q

MEN 2 a tumors and bold most common?

A

MEDULLARY THYROID CANCERS, pheo, PT tumors

344
Q

MEN 2b and bold most common?

A

medullary thyroid, pheo, MUCOSAL NEUROMAS, marfanoid body habitus

345
Q

What is carcinoid syndrome?

A

slow growing tumors which cause secretion of vasoactive substances and can be life threatening

346
Q

Some of the vasoactive substances secreted by carcinoid syndrome?

A

serotonin (vasoconstriction), histamine (vasodilation), kallikrein (vasodilation)

347
Q

Cells which secrete vasoactive substances in carcinoid syndrome?

A

enterochromaffin cells

348
Q

Most carcinoid syndrome tumors are where in the body?

A

GI tract; metabolic products are released into the portal circulation and destroyed by the liver before causing systemic effects- little sx

349
Q

4 other places carcinoid tumors may develop?

A

lung, pancreas, thymus, liver

350
Q

What is the life threatening form of carcinoid syndrome and what precipitates it?

A

carcinoid crisis; physical manipulation of tumor

351
Q

What are some other times carcinoid crisis can occur?

A

induction of anesthesia, mets of tumor to liver and shuts down liver

352
Q

Classic sign of carcinoid syndrome and caused by?

A

cutaneous flushing; kallikrein

353
Q

What substance causes right sided HF in carcinoid syndrome? What ab dramatic BP swings? And bronchospasm? And profuse diarrhea and abdominal pain?

A

serotonin; kallikrein and histamine; kallikrein and histamine; serotonin

354
Q

Some other s/s carcinoid syndrome?

A

cyanosis, N/V, hepatomegaly, RP and pelvic fibrosis, cough, wheezing, dyspnea, pulmonic and tricuspid valve thickening and stenosis, endocardial fibrosis

355
Q

Diagnosis of carcinoid syndrome?

A

serotonin metabolites in the urine or elevated plasma levels of chromogranin A

356
Q

Pretreatment for surgical removal of carcinoid tumor consists of?

A

hypotension that may be caused by manipulation of tumor; H1 and H2 blockers (benadryl and zantac)

357
Q

How soon before surgery in carcinoid tumor pt should you start ocreotide?

A

2 weeks

358
Q

2 diagnostic tests before carcinoid tumor surgery?

A

x ray to eval extraintestinal manifestations, Echo to diagnose right sided heart disease

359
Q

2 examples of serotonin antagonists are?

A

ocreotide and somatostatin

360
Q

What’s the 1/2 life and dose of ocreotide?

A

100 min; 100 mg SQ 2-3 times daily

361
Q

How does Sandostatin/ocreotide work?

A

inhibits all bioactive substances

362
Q

1/2 life of somatostatin?

A

2-3 min

363
Q

Type of medication for carcinoid syndrome which is an inhibitory peptide to antagonize and suppress the release of tumor products?

A

stomatostatin

364
Q

How does somatostatin work?

A

it binds to receptors of tumor cells and results in decreased secretion

365
Q

Be ready to treat what 4 things during surgery for pt with carcinoid syndrome?

A

decreased peripheral vascular resistance, hypotension, bronchospasm, HTN

366
Q

What pressor should you use for refractory hypotension in pt with carcinoid syndrome?

A

vasopressin

367
Q

Avoid histamine releasing substances such as what 3 meds during carcinoid syndrome surgery?

A

morphine, cisatracurium, suxxs

368
Q

3 meds that are good to give during carcinoid syndrome surgery?

A

steroids, H2 blockers, ocreotide

369
Q

Is spinal anesthetic ok for carcinoid syndrome surgery?

A

yes

6901 (18 decks)

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