6901 endo Flashcards
1
Q
Examples of peptide hormones?
A
insulin, ADH, angiotensin, erythropoeitin, GH
2
Q
How are peptides released in to the blood stream?
A
exocytosis of granules they’re stored in and released in to ECF
3
Q
Some examples of amine hormones?
A
catecholamines (epi, serotonin, norepi, dopa) and thyroxine
4
Q
Lipid hormones are derived from where?
A
cholesterol
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
6
Q
Examples of lipid hormones?
A
aldosterone, estrogen, progesterone, adrenalcorticoids-cortisol, aldosterone
7
Q
How are lipids transported?
A
simple diffusion
8
Q
Where are hormone receptors located?
A
on the surface of the cell or inside the cell
9
Q
Hormone receptors display a high affinity for what?
A
right hormone
10
Q
What directs the hormone to the correct target organ?
A
location receptor
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)
12
Q
3 hormones which use cAMP (there are others)?
A
vasopressin, TSH, parathyroid hormone
13
Q
What are 2 other 2nd messengers?
A
Ca, cyclic GMP
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
15
Q
Hormone receptor number is inversely related to?
A
concentration of circulating hormone
16
Q
Hormone secretion and suppression are caused by what three things?
A
biorhythms (circadian), neural controls (pain, smell, taste), feedback
17
Q
Homeostasis is controlled by what 2 systems?
A
endocrine and nervous
18
Q
6 functions endocrine system regulates?
A
behavior, growth, metabolism, fluid status, development, reproduction
19
Q
The 8 endocrine glands are?
A
pancreas, thyroid, parathyroid, adrenal glands, placenta, testes, ovaries, pituitary gland
20
Q
This gland secretes hormones that effect all other endocrine glands?
A
pituitary
21
Q
4 functions of pituitary gland?
A
homeostatic, developmental, metabolic, and reproductive
22
Q
How big is the pituitary gland?
A
small, size of pea, 500 g
23
Q
Where is the pituitary gland located?
A
base of brain in sella turcica
24
Q
What structure connects the pituitary gland to the hypothalamus?
A
hypophyseal stalk
25
The pituitary gland is between the ______ _______ and the _____ ________
optic chiasm, optic tracts
26
What regulates hormone release from the anterior and posterior pituitary?
hypothalamus
27
Another name for the anterior pituitary and the posterior pituitary?
adenohypophysis; neurohypophysis
28
Why is the posterior pituitary unique?
it receives synthesized hormones from the hypothalamus
29
6 hormones released from anterior pituitary?
GH, ACTH, thryotropin (TSH), FSH, LH, prolactin
30
How does GH act?
similarly to insulin-metabolic and endocrine ftns thruout the body- skeletal muscle development, growth, carb, and protein metabolism regulation
31
What does ACTH do?
stimulates release of cortisol and androgens from adrenal glands
32
What does thyrotropin do?
growth and metabolism of thyroid gland and stimulates thyroid gland to release TH/thyroid hormones
33
What does FSH do and where is it secreted?
stimulates estrogen production and ovarian follicle development in females and is secreted from ovaries and spermatogenesis in males
34
What does LH do?
stimulates progesterone production and ovulation and corpeus luteum in females and testosterone production and spermatogenesis in males (??)
35
What does prolactin do?
stimulates lactation from mammary glands, mammary gland development, inhibits synthesis and secretion of LH and FSH, this hormone is markedly increased during pregnancy
36
What % of the pituitary gland is the anterior lobe?
80%
37
5 causes of hyposecretion from the anterior pituitary gland?
large nonfunctional pituitary tumors, postpartum shock/Shehan syndrome, irradiation, trauma, hypophysectomy (surgical removal of pituitary gland)
38
What is panhypopituitarism?
lack of pituitary hormones rather than just lack of 1 and it's more common than lack of 1
39
What 3 hormones are commonly effected with panhypopituitarism?
TSH, ACTH, gonadotropic hormones
40
5 manifestations of congenital anterior hypopituitarism?
micropenis, midline defects, optic atrophy, hypoglycemia, poor growth
41
A decrease in what hormone leads to decrease in thyroid function?
TSH
42
What hormone would decrease glucocorticoid production by the adrenal cortex?
ACTH
43
A decrease in what hormone would cause a depressed sexual development and reproductive function?
gonadotropic hormone secretion
44
Hormone deficiency symptoms: hypoglycemia, vomiting, malaise?
cortisol
45
Hormone deficiency symptoms: fatigue, constipation, cold intolerance, bradycardia?
thyroxine
46
Hormone deficiency symptoms: delayed puberty, amenorrhea, micropenis?
sex steroids
47
Hormone deficiency symptoms: short stature, hypoglycemia?
growth hormone
48
Hormone deficiency symptoms: polyuria, polydyspsia, hypernatremia, lethargy, dehydration?
ADH
49
A treatment of hypopituitarism? What 2 meds may be required afterwards?
surgical removal- steroids, thyroid hormone replacement
50
What do you have to watch out for after surgical removal of the pituitary and what's the treatment for that?
DI- vasopressin
51
Usual approach for removal of pituitary? Whats the other approach?
transphenoidal/nasal; transcranial
52
Why is a precordial particularly important for surgical pituitary removal?
to detect venous air embolism bc in sitting position (low ETCO2)
53
What gas do you need to avoid for removal of ant pituitary? Why?
N20; surgeon injects air and N20 is more soluble than nitrogen so it diffuses in more quickly and can expand a closed space
54
Do you want muscle relaxation for surgical removal of pituitary?
yes
55
Why do you need a quick, smooth emergence for surgical removal of pituitary? And what can help facilitate that?
allow for neuro checks; give lido to prevent bucking
56
Why would BP increase during removal of pituitary?
surgeon injects local with epi
57
What should you prepare the pt for post operatively if having pituitary removed?
will have nasal packing and feel congested/pressure
58
Potential complications of transphenoidal pit removal and which ones are not common?
meningitis, CSF leak, ischemic stroke, visual loss; not common: epistaxis, symptomatic hyponatremia, transient DI, cranial nerve damage
59
Most pituitary tumors are?
hypersecreting pituitary adenomas
60
What is a common hormonal abnormality associated with pituitary adenomas?
excessive prolactin secretion with lacturia
61
The most common hypsersecretion pituitary tumors secrete what 3 hormones?
prolactin, ACTH, GH
62
ACTH excess is called?
Cushing's disease
63
Prolactin secreting tumors produce what 3 effects?
infertility, amenorrhea in women, and decreased libido in men
64
What med can you treat decreased libido with?
bromocriptine (dopamine agonist)
65
Other name for GH?
somatotropin
66
Releasing and inhibiting hormones from where regulate GH activity throughout the day?
hypothalamus
67
How do the levels of GH change throughout one's lifetime?
rate of secretion is increased in childhood, followed by an even greater rise in adolescence. levels plateau in adulthood and drop in old age
68
What increases amt of GH secreted?
stress- OR, hypoglycemia, exercise, deep sleep
69
How is GH regulated?
- feedback
70
How does GH increase blood glucose levels?
decreases the sensitivity of cells to insulin and inhibits glucose uptake in to the cells
71
T/F: Feedback can be initiated by the peripheral target cells to only the hypothalamus?
F: feedback can be initiated to the pituitary too
72
What is hypersecretion of GH usually caused by?
GH secreting pituitary adenoma
73
Hyposecretion of GH is called what? And what does that do to blood sugar?
dwarfism, hypoglycemia
74
If sustained hypersecretion of GH occurs after adolescence it is referred to as?
acromegaly
75
If GH secretion is elevated before adolescence it is called?
gigantism
76
What effects does acromegaly have on the bone, organs, lung volumes, and facial features?
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
77
Treatment of hypersecretion of GH?
removal of pituitary tumor
78
4 cardiac conditions associated with acromegaly?
CM, HTN, accelerated atherosclerosis, LVH
79
2 endocrine abnormalities from acromegaly?
glucose intolerance, DM
80
Some anesthetic considerations for pt w hypersecretion of GH?
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
81
Posterior pit gland secretes what 2 hormones?
ADH, oxytocin
82
increased serum osmolarity= __ ADH?
increased
83
This hormone stimulates milk ejection during lactation?
oxytocin
84
This hormone controls water reabsorption and excretion in the kidney
ADH
85
This hormone stimulates uterine smooth muscle contraction?
oxytocin
86
Derivatives of oxytocin are used for what 2 things in L&D?
inducing labor, decreasing postpartum bleeding
87
What receptor does ADH act on in renal collecting ducts?
V2
88
ADH is released at which mOsm/L value?
284
89
Normal mOsm/L?
285-290
90
2 things that stimulate ADH release?
10-20% decrease in plasma volume or blood pressure
91
ADH secretion increases with what 4 things?
pain, hemorrhage, emotional stress, nausea
92
Which organ increases ADH synthesis and release?
hypothalamus
93
Baroreceptors send signals via which nerves to the hypothalamus to tell the hypothalamus to increase ADH synthesis and release?
vagus, glossopharyngeal
94
DI hallmark symptoms?
polyuria, polydypsia
95
DI leads to dehydration and what type of Na balance?
hypernatremia
96
DI has what type of concentration of ADH?
low
97
Normal urine osm values? And what are they in DI?
500-800;
98
2 types of DI?
neurogenic-destruction of post pit where there is inadequate secretion of ADH and nephrogenic- inability of renal collecting duct receptors to respond to ADH
99
S/S DI?
hyperreflexia, weakness, lethargy, seizures, coma
100
The difference in the 2 types of DI is the response to desmopressin. In neurogenic, desmopressin does what? In nephrogenic desmopressin does what?
neurogenic: concentrates urine; nephrogenic: does not concentrate urine
101
DI after pituitary gland surgery is generally d/t reversible trauma to posterior pituitary and is ______?
transient
102
Treatment for DI short term and long term?
short term- vasopressin; long term- desmopressin
103
Is vasopressin admin before surgery necessary with partial DI?
usually not because ADH is released in response to surgery
104
What 3 parameters should be measured qh and in recovery for patients with DI?
UO, plasma osm, serum Na
105
What does treatment of complete DI target?
increasing receptor response to ADH
106
What type of fluids for DI unless serum osm reaches 290, then what?
isotonic; then hypotonic fluids
107
What happens in SIADH in the renal tubules when there is hypoosmolarity?
water is reabsorbed in renal tubules
108
Emergence may be slow/fast in SIADH pt?
slow
109
4 s/s of SIADH?
weight gain, increased skeletal muscle weakness, mental confusion, convulsions
110
4 drugs associated with increased ADH release?
tricyclic antidepressants, tegretol, diabanase, nicotine
111
6 causes of SIADH?
hypothyroidism, pulmonary neoplasia, head trauma or infection, intracranial tumors, posterior pituitary surgery, ADH secreting neoplasms (small cell carcinoma of the lung)
112
Treatment for mild SIADH and severe SIADH?
mild: fluid restriction (800 mL/day); severe w neuro s/s: hypertonic saline with lasix
113
Serum osmolarity in SIADH vs DI?
SIADH 290
114
Serum Na in SIADH vs DI?
SIADH 145
115
Gland that helps regulate Ca balance?
thyroid
116
Where is the thyroid gland located?
immediately below the larynx and on either side of and anterior to trachea
117
What does the thyroid gland need to produce the hormones?
iodide
118
Which 2 nerves are in intimate proximity to thyroid gland?
RLN, external motor of SLN
119
The thyroid gland is composed of follicles filled w what?
thyroglobulin, an iodinated protein that serves in thyroid hormone synthesis
120
What 3 hormones does the thyroid gland secrete?
T3, T4, calcitonin
121
Does the thyroid gland have much blood supply?
yes it has a very rich blood supply
122
Thyroxine/T4 is what % of thyroid hormone and is it potentn in the blood?
93% and it's less potent in the blood
123
T3 is what % of thyroid hormone and is it potent in the blood?
7% and it's more potent in the blood
124
Normal adult level of T3 and T4?
T3- 70-132; T4- 5-12
125
How is iodine absorbed in to the blood?
it's reduced to iodide in the GI tract then absorbed in to the blood
126
How does iodide trapping occur?
when active transport carries iodide into the thyroid follicular cell
127
Where is iodide converted to oxidized iodine?
thyroid
128
Why does iodide need to be converted to oxidized iodine?
it is capable of combining w tyrosine residues of thyroglobulin
129
Normal quantities of thyroid hormone depend on?
exogenous iodine
130
Which T hormone (hormone) is converted to the other T hormone?
T4 is converted to T3 at the tissue sites
131
Which thyroid hormone primarily inhibits TRH and TSH in negative feedback?
T3
132
How do T3 and T4 have a direct effect on the heart?
+ 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
133
This hormone stimulates every tissue in the body to produce proteins and increase the amt of O2 used by the cells?
thyroid
134
Peak age of Grave's Disease?
40
135
Amiodarone is rich in what and therefore can cause what?
iodine; hypo or hyperthyroidism
136
TSH and T4 diagnosis for thyrotoxicosis?
decreased TSH, increased T4
137
Some etiologies of Grave's disease?
benign follicular adenoma, iodine excess, thyroid hormone OD, goiter, thyroiditis, TSH secreting pituitary tumor, thyroid cancer
138
These drugs inhibit thyroid hormone synthesis?
methimazole, propylthiouracil, carbimazole
139
These drugs prevent thyroid hormone release?
K, sodium iodide
140
These drugs mask signs of over adrenergic activity in hyperthyroidism?
atenolol, propranolol
141
This destroys thyroid cell function?
radioactive iodine
142
What happens to hair, breasts, fingers, and extremities in hyperthyroidism?
fine straight hair, enlarged breasts, clubbing fingers, localized edema
143
Some preop anesthetic considerations for hyperthryoidism?
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
144
3 anesthetic drugs to avoid with hyperthyroidism?
ketamine, cisatracurium, atropine
145
Is there an increase in MAC with hyperthyroidism? Explain
no, but the increased CO and blood volume may increase the inhalational requirements
146
How should you intubate a pt in hyperthyroidism?
in deep level of anesthesia
147
How should one treat intraoperative hypotension in pt with hyperthyroidism?
w direct acting like phenylephrine bc the indirect acting can increase catecholamines
148
What 2 acid base symptoms stimulate SNS and should be avoided in those with hyperthyroidism?
hypercarbia, hypoxia
149
Why do you have to position hyperthryoidism pts carefully?
decreased bone density and predisposition to osteoporosis
150
What do you have to keep in mind regarding NMB in pts with hyperthyroidism?
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
ETT with NIM monitoring is used for hyperthyroidism surgeries because?
to assess RLN
152
ETT with NIM: red and blue electrodes should be where?
right on right, blue on left
153
Most serious threat to hyperthyroidism pt undergoing surgery?
thyroid storm
154
3 events that may precipitate thyroid storm?
trauma, surgery, labor & delivery
155
Thyroid storm presentation is similar to what 4 things?
pheo, MH, light anesthesia, NMS
156
Mortality rates of thyroid storm are as high as what?
30%
157
3 s/s of thyroid storm during surgery?
fever > 38.5, HTN, afib, tachycardia
158
Other s/s thyroid storm in awake pt?
agitation, confusion, tremor, N/V, CHF, shock/metabolic acidosis, abnormal LFTs
159
Treatment for thyroid storm?
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
3 post op complications w hyperthyroid pt?
RLN damage, hematoma, hypothyroidism
161
S/s unilateral RLN damage? S/s bilateral RLN damage?
unilateral: hoarseness; bilateral: aphonia and stridor (reintubate)
162
Hypoparathyroidism will occur how long after hyperthyroidism surgery?
24-72 h
163
Which problem, MH or thyroid storm is more of a hypermetabolic state?
MH
164
Differentiating s/s of MH versus thyroid storm?
MH is sudden unexplained rise in ETCO2, trismus, and RAPID temp rise; temp will usually rise later in thyrotoxicosis
165
6 causes of hypothyroidism?
autoimmune mediated inflammation, iodine deficiency (lithium), medications, surgery for hyperthyroid, neck irradiation, radio iodide therapy
166
Diagnosis of primary hypothyroidism versus secondary hypothyroidism?
primary: decreased T4 and or T3, increased TSH; secondary: decreased T4, T3, TSH
167
95% of all hypothyroidism cases are?
Hashimoto thyroiditis
168
Treatment of hypothyroidism involves replacement of which hormone?
T4
169
Some unthought of s/s of hypthyroidism?
CHF, gastroparesis, hypoventilation, hyponatremia, poor mentation
170
What happens to the hairline, tongue, and muscles in hypothryoidism?
receding hairline, thick tongue, muscle aches and weakness
171
Late clinical manifestations of hypothyroidism?
bradycardia, wt gain, subnormal temp, decreased LOC, thickened skin, cardiac complications
172
Careful eval of airway is needed for what 3 reasons in hypothyroidism pts?
enlarged thyroid gland, enlarged tongue, myexedematous infiltration of vocal cords
173
What are 2 reasons that pts with severe hypothyroidism are at risk for problems during surgery?
myocardial ftn and baroreceptor ftn may be depressed
174
Is MAC in hypothyroid pts affected?
no
175
Why would RSI be good in hypothyroid pt?
increased risk of aspiration d/t slower gastric emptying
176
A good medication for induction in hypothyroid pt?
ketamine
177
Why is respiratory depression following administration of opioids a possibility w hypothyroid pts?
baroreceptor response to hypercarbia and hypoxia may be depressed; large tongue and goiter hypoxia and hypercarbia may be present
178
What cardiac effects may be present in hypothyroid pt?
hypotension, myocardial depression, plasma volume may be reduced
179
If hypothyroid pt is experiencing muscle weakness what do you need to keep in mind?
may be sensitive to nondepolarizers
180
What medication may be necessary intraoperatively in hypothyroid pt d/t potential for adrenal insuffiency r/t stress?
cortisol
181
Why may hypothyroid pt have delayed recovery/emergence?
hepatic metabolism and renal clearance of drugs may be slower and have prolonged effect
182
Why may response to inotropic drugs in hypothyroid pt be diminished?
the # of beta receptors is decreased
183
Myexedema coma may be precipitated by what?
surgery, usually in elderly pts
184
Myexedemia is more common in what pts and what are 3 symptoms?
elderly; hyponatremia, hypothermia, hypoventilation
185
Where are parathyroid glands located? And how many do most ppl have?
posterior surface of thyroid gland; 4 (some have 3 or 5)
186
What is the blood supply to the parathyroid glands?
inferior thyroid arteries
187
Parathyroid hormone is released from what in response to what?
chief cells in parathyroid gland in response to low serum ionized Ca
188
PTH is also released in response to what 2 electrolyte abnormalities?
hyperphosphatemia, acute hypomagnesemia
189
PTH does what to extracellular calcium and extracellular phosphate?
increases;decreases
190
What would be a fairly common cause of parathyroid gland hypertrophy?
lactation and pregnancy which cause a sustained deficit in ionized Ca and therefore result in hypertrophy
191
How does PTH increase Ca?
it acts on bone to mobilize Ca; osteoclasts stimulate rapid absorption of Ca from bone to ECF
192
What does increased ECF Ca do to PTH?
decreased PTH release stimulating deposition of Ca
193
3 ways in which PTH increases Ca?
increased decomposition of bone, releasing Ca, increased absorption of Ca from food by intestines, reabsorption of Ca from urine by kidneys
194
This hormone is secreted from the thyroid in response to elevated ionized Ca?
calcitonin
195
Which cells in the thyroid secrete calcitonin?
parafollicular/C cells
196
How does PTH increase renal absorption of Ca?
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
Why does kidney disease or absence of PTH result in hyopcalcemia?
enzyme in kidneys is not formed and effect of vit D on Ca and phosphate regulation is lost
198
Parathyroid dysfunction affects what 3 areas of the body?
bone, intestinal tract (absorption of Ca), kidney (formation of vit D, reabsorption of Ca, and increased excretion of phosphate)
199
Hyperparathyroidism= ______calcemia
hyper
200
S/s hyperca?
HTN, ventricular dysrhythmias, shortened QTI, impaired renal concentrating ability, renal failure, polyuria, polydipsia, ileus, N/V, muscle weakness, osteoporosis, mental status changes
201
The enzyme vitamin D1 hydroxylase converts what to the active form 125 OH vit D? And at what level does this increase Ca absorption?
liver byproduct 25 hydroxy vit D; small intestine
202
Normal Ca levels?
8.8-10.4
203
90% of time parathyroidism is due to what?
adenoma
204
Hyperparathyroidism is where PTH levels are high in spite of?
high serum Ca
205
In hyperparathyroidism calcifications may be formed in which organs leading to dysfunction?
pancreas-pancreatitis, kidney- nephrolithiasis, polyuria, heart- bradyarythmias, BBB, heart block, stomach- peptic ulcer
206
What type of anesthesia can removal of PT gland be performed under?
general or cervical plexus block with MAC
207
Severe hypercalcemia (what value is that) is treated with what?
>13-16; isotonic saline and loop diuretics
208
Some anesthetic considerations for pts with hyperparathyroidism?
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
How does alkalosis lower Ca?
it shifts Ca to protein bound form and decreases serum levels of Ca
210
Why would one have hypoparathyroidism?
inadequate secretion of PTH or peripheral resistance to its effect
211
3 causes of hypoparathyroidism?
removal of PT tissue, radiation, chronic Mg deficiency (alcoholism)
212
Why do ppl with hypoparathyroidism experience muscle spasms and tetany?
threshold of excitable membranes is lowered
213
Post op parathyroidectomy- beware of what 2 things?
laryngospasm, resp distress d/t edema, bleeding, or bilat RLN damage
214
Treatment for post op parathyroidectomy?
Ca Cl IV slow
215
Is being unable to talk after a parathyroidectomy normal?
no-maybe bilat RLN damage and need to intubate
216
How does insulin lower blood sugar?
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
What are islets of langerhans?
microscopic collections of cells scattered throughout the pancreas which produce hormones
218
How do the hormones produced by the islets of langerhans take effect?
they are directly secreted in to the capillary blood vessels rather than entering the ducts
219
What is the blood supply of the islet cells like?
abundant blood supply
220
What % of beta cell ftn is lost in Type I DM before hyperglycemia occurs?
80-90%
221
What is the short and sweet patho description of Type I DM?
glucose is presence in abundance but unable to reach the cells d/t lack of insulin
222
Pathophysiology of Type II diabetes?
impaired insulin secretion, peripheral insulance resistance, excessive hepatic glucose production d/t environmental, genetic, lifestyle factors
223
When blood glucose rises >?, glucose spills in to the urine?
180-200
224
When insulin is deficient what does the liver do?
liver increases its glucose output so intracellularly glucose is low but extracellularly glucose is high
225
Glucose starved cells use what for fuel?
fat and protein
226
The increased breakdown of triglycerides to free fatty acids and glycerol contributes to what (in diabetic pts)?
atherosclerotic and angiopathic changes
227
What becomes the main energy source in the diabetic pt?
fatty acids
228
Why are increased fatty acids bad in the diabetic pt?
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
What causes weight loss, weakness, and organ dysfunction in diabetic pt?
protein catabolism, free amino acids are converted in the liver into glucose
230
What does A1C mean?
structural tissue proteins and hemoglobin become glycosolyated, which contributes to organ damage
231
How much more likely is diabetic pt to have HTN than nondiabetic pt?
twice as likely
232
A diabetic pt with sudden hypotension- you should think?
silent MI
233
Risk of MI is __-__ times higher in diabetic that nondiabetic?
2-10
234
Risk of stroke is how much larger in diabetic versus nondiabetic?
twice
235
Risk of PVD is __ to ___ higher in diabetic versus nondiabetic?
5-10 x greater
236
Autonomic neuropathy leads to dysfunction of vagus nerve resulting in?
orthostatic hypotension, tachycardia, dysrthymias
237
Autonomic neuropathy does what to GI system?
risk for aspiration, slowed gastric emptying, reflux esophagitis
238
What happens to the diabetic pt's response to atropine and propranolol?
reduced response d/t autonomic neuropathy
239
Some other complications of autonomic neuropathy?
lack of sweating, lack of hr variability, resting tachycardia, asymptomatic hypoglycemia
240
Are diabetics with gastroparesis mask candidates?
no
241
Why do you have to be careful with preop sedation and post op pain meds in diabetic pts?
impaired respiratory response to hypoxia
242
4 labs necessary to eval kidney ftn in diabetic pt?
UA, BUN, creat, lytes
243
Stiff joint syndrome is seen more with which type of diabetic pt?
Type I
244
Test for stiff joint syndrome?
+ prayer sign
245
What 2 parts of ortho system may be involved in stiff joint syndrome and make intubation difficult in diabetic pt?
TJ joint and C spine limited movement
246
A1C
7
247
Standard types of measurement of glucose before surgery?
venous plasma or serum
248
Why might chronic hyperglycemia leave the pt dry?
it's associated w osmotic diuresis
249
What is a pt at risk for if they take metformin before surgery?
hypotension, renal hypoperfusion = lactic acidosis and accumulation in renal impairment, CHF, liver disease
250
Metformin should be held how long before surgery?
>48 hours
251
What type of surgeries do you have to be cautious ab in pts with an insulin pump?
electrocautery and radiation
252
How much dose 1 unit of insulin lower blood glucose?
40-50 mg/dL
253
Beware of anaphylaxis with what drug in pts taking NPH or protamine zinc insulin?
protamine sulfate
254
What causes hyperglycemia intraoperatively?
activation of SNS, catecholamine, cortisol, and GH secretion
255
You can see LOC/seizures at blood glucose
50
256
Some causes of hypoglycemia?
beta blockers, severe liver disease, toxins (ethanol), gastric bypass surgery, sepsis, insulin secreting tumor
257
In a 70 kg pt, 15 mL of D50 raises the blood glucose concen by what?
30 mg/dL
258
1 mL of D50 raises blood glucose concen by how much?
2 mg/dL
259
DKA is usually in which type of diabetes?
I
260
DKA usually develops over how long?
24 hours
261
Triad for DKA?
hyperglycemia, acidosis, ketonemia
262
In DKA blood sugar is usually > than what?
250
263
6 precipitants of DKA?
critical illness, MI, trauma, CVA, burn, infection
264
S/s DKA?
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
2 complications associated with DKA?
gangrene and ischemic lower extremity
266
Treatment for DKA?
isotonic fluids, K, insulin
267
Is mortality higher with DKA or HHS?
HHS
268
Why is HHS life threatening?
it's a hyperglycemic state that leads to diuresis and severe dehydration
269
Glucose is usually > than what in HHS?
600
270
S/s HHS?
hyperglycemia, polyuria, polydipsia, hypovolemia, hypotension, tachycardia, organ hypoperfusion, acidosis, risk of thrombus, hyperosmolality, seizures, coma
271
Hypoosmolality > than mOsml induces dehydration of neurons?
360
272
What does severe hyperglycemia do to Na?
produces false hyponatremia
273
With each 100 mg/dL increase in blood sugar, plasma Na concentration lowers by?
1.6 mEq/L
274
In HHS if plasma osmolarity is >320, what fluid should be given and until when?
large volumes 1000-1500 mL/h of 1/2 NS until osmolarity
275
What are some hazards to rehydrating in elderly?
rehydrate slowly because they are prone to cerebral edema and CHF
276
Difference in the pH of DKA vs HHS?
pH 7.3 in HHS
277
Difference in serum osmolarity between DKA and HHS?
serum osmolarity is greater in HHS
278
Difference in mental obtundation in DKA vs HHS?
mental obtundation is present in HHS but variable in DKA
279
Difference in serum K with DKA vs HHS?
normal or slight increase in DKA; normal or lower in HHS
280
Function of adrenal glands?
synthesize and store essential hormones
281
Outer and inner part of adrenal gland?
outer= cortex; inner= medulla
282
3 hormones secreted by adrenal cortex?
mineralcorticoids (aldosterone); glucocorticoids (cortisol); androgens (dehydroepiandrosterone)
283
Hormone secreted by adrenal cortex which maintains and regulates immune and circulatory function and effects carbo, protein, and fatty acid metabolism?
glucocorticoids/cortisol
284
This adrenal cortex hormone regulates ECF volume and K thru reabsorption of Na and secretion of K?
mineralcorticoids (aldosterone)
285
4 times which produce an increase in aldosterone?
surgery, CHF, hypotension, hypovolemia
286
4 things which stimulate release of aldosterone?
angiotensin II, ACTH, pituitary hormones, hyperkalemia
287
What stimulates synthesis of cortisol?
ACTH
288
These hormones enhance gluconeogenesis and inhibit peripheral glucose utilization?
glucocorticoids/cortisol
289
Inner part of adrenal gland and the hormones it secretes?
adrenal medulla; norepi, epi, dopamine
290
This catecholamine constitutes 80% of adrenal catecholamine output?
epi
291
Because glucocorticoids are structurally related to aldosterone, they promote what?
Na retention and K excretion
292
This hormone is responsible for vascular and smooth muscle response to catecholamines?
glucorticoids/cortisol
293
Mechanism for regulating cortisol secretion?
ACTH, CRF
294
Most potent regulator of ACTH?
cortisol
295
4 things cortisol does?
gluconeogenesis, protein mobilization, fat mobilization, stabilizes lysosomes
296
Cortisol had direct - feedback effect on what and inhibits release of what? then, the anterior pituitary decreases release of?
hypothalamus; CRH and CRF; ACTH
297
Secretion of what 3 things follow circadian rhythms?
ACTH, cortisol, and CRH
298
Daily production of cortisol is usually?
15-30 mg
299
Increased aldosterone production, which is a dysfunction of the adrenal cortex, results in?
excess mineralocorticoid
300
2 types of increased aldosterone production-primary and 2ndary- are caused by what?
primary: (Conn syndrome), from adrenal adenoma independent of stimulus; 2ndary: increased renin production
301
3 s/s of increased aldosterone and treatment for it is?
HTN, ECF volume weakness; surgical removal of tumor-lap adrenalectomy
302
Increased aldosterone causes what for the Na/K pump?
Increased Na/K exchange so a decrease in K and retention of Na
303
A good drug to manage HTN for hyperaldosteronism?
Spironolactone (aldosterone antagonist)
304
You should avoid what w the vent in a hyperaldosteronism pt?
hyperventilation bc it will lower the K further
305
Why do you have to be careful with NMB in hyperaldosteronism pts?
hypokalemia may enhance the MR
306
Overproduction of cortisol is what disease?
Cushing's
307
Causes of Cushing's?
anterior pituitary or adrenal tumors
308
Most common cause of Cushing's?
exogenous administration of corticosteroids
309
S/s Cushing's?
central obesity with thin extremities, HTN, moon face, striae, thin, atrophic skin, muscle weakness, increased intravascular fluid volume, hypokalemia, fatiguability
310
Anesthetic management for pt with Cushing's?
lytes, Spironolactone, careful w positioning, conservate MR if muscle weakness present, increased risk of infection, thromboemboli are more common, need supplemental steroids
311
Why are thromboemboli more common in Cushing's pt?
HTN, obesity, increased Factor VIII, high hct
312
Addison's disease is deficiency in what 3 hormones?
adrenal androgens, glucocorticoids, mineralcorticoids
313
2 causes of Addison's disease?
TB, autoimmune diseases
314
Primary cause of Addison's? And what are some causes of that?
destruction of adrenal gland; congenital, infection, malignancy, trauma, HIV, adrenal hemorrhage
315
2ndary cause of Addison's?
decrease in ACTH
316
Tertiary cause of Addison's?
d/t exogenous admin of glucocorticoids and cortisone admin
317
S/s Addison's?
(cortisol def): fatigue, weakness, weight loss, abdominal pain, diarrhea, hypoglycemia; aldosterone def: volume depletion-orthostatic hypotension, hyponatremia, hyperkalemia, hyperpigmentation
318
Treatment of Addison's?
100 mg Hydrocortisone or Prednisone
319
Which anesthetic drug can cause adrenal insufficiency and should avoided in those pts prone to adrenal insufficiency?
etomidate
320
Benefits of steroid therapy are weighed down by some risks such as?
glucose intolerance, stress ulcers, impaired wound healing, immunosuppression
321
What is acute adrenal crisis?
sudden onset of severe adrenal insufficiency
322
How does acute adrenal crisis progress and what can cause it?
very rapidly and is life threatening; stress
323
Main sign of acute adrenal crisis?
HD instability
324
Have high suspicion of acute adrenal crisis if?
hx of autoimmune, exogenous steroid use, HD instability, hyperpigmentation
325
Pheo is a catecholamine secreting tumor which consists of cells originating from?
embryonic neural crest (chromaffin tissue)
326
Are pheos usually malignant and in both adrenal glands?
usually benign and in one adrenal gland
327
4 s/s of pheo?
paroxysmal headache, sweating, HTN, palpitations
328
First indication of pheo can be?
intraop HTN and tachycardia
329
A pheo diagnosis is made w what and a false + can be caused by what?
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
Should you give an alpha or beta blocker first in pheo pt?
alpha bc beta may cause dilation in skeletal muscles and worsen HTN
331
Alpha blocker and dose for pheo?
Phenoxybenzamine 10 mg BID, increasing q 2-3 days by 10-20 mg for a max dose of 1mg/kg
332
Beta blocker helps control what in pheo pt?
reflex tachycardia
333
When is beta blocker added in pheo pt?
several days after initiation of alpha blocker; to avoid the possibility of unopposed alpha constriction resulting in severe HTN and ischemia
334
5 preop treatment endpoints for pheo pt?
1) BP 24 hours; 2) presence of orthostatic hypotension (not
335
3 beta blockers good for pheo?
propranolol (20-80); atenolol (12.5-25); metoprolol (25-50)
336
Avoid what 5 drugs/actions in pheo pt intraop?
ephedrine, ketamine, hypoventilation (SNS stimulation); atracurium, MS (histamine)
337
6 good drugs to give in pheo pt?
alpha blockers, beta blockers, MgSO4, nicardipine, nitroprusside and nitroglycerin
338
Post of HTN in pheo pt may indicate?
another tumor
339
Treatment for post op hypotension in pheo pt?
fluids are initial therapy, phenyl pushes and gtt, Norepi gtt
340
One reason why hypotension is common in post op pheo pt- what type of blockade is persistent?
alpha blockade
341
What is MEN?
overactivity of 2+ endocrine glands
342
MEN 1 disorders and bold the most common occurring tumor?
pituitary adenoma, PARATHYROID HYPERPLASIA, pancreatic tumors
343
MEN 2 a tumors and bold most common?
MEDULLARY THYROID CANCERS, pheo, PT tumors
344
MEN 2b and bold most common?
medullary thyroid, pheo, MUCOSAL NEUROMAS, marfanoid body habitus
345
What is carcinoid syndrome?
slow growing tumors which cause secretion of vasoactive substances and can be life threatening
346
Some of the vasoactive substances secreted by carcinoid syndrome?
serotonin (vasoconstriction), histamine (vasodilation), kallikrein (vasodilation)
347
Cells which secrete vasoactive substances in carcinoid syndrome?
enterochromaffin cells
348
Most carcinoid syndrome tumors are where in the body?
GI tract; metabolic products are released into the portal circulation and destroyed by the liver before causing systemic effects- little sx
349
4 other places carcinoid tumors may develop?
lung, pancreas, thymus, liver
350
What is the life threatening form of carcinoid syndrome and what precipitates it?
carcinoid crisis; physical manipulation of tumor
351
What are some other times carcinoid crisis can occur?
induction of anesthesia, mets of tumor to liver and shuts down liver
352
Classic sign of carcinoid syndrome and caused by?
cutaneous flushing; kallikrein
353
What substance causes right sided HF in carcinoid syndrome? What ab dramatic BP swings? And bronchospasm? And profuse diarrhea and abdominal pain?
serotonin; kallikrein and histamine; kallikrein and histamine; serotonin
354
Some other s/s carcinoid syndrome?
cyanosis, N/V, hepatomegaly, RP and pelvic fibrosis, cough, wheezing, dyspnea, pulmonic and tricuspid valve thickening and stenosis, endocardial fibrosis
355
Diagnosis of carcinoid syndrome?
serotonin metabolites in the urine or elevated plasma levels of chromogranin A
356
Pretreatment for surgical removal of carcinoid tumor consists of?
hypotension that may be caused by manipulation of tumor; H1 and H2 blockers (benadryl and zantac)
357
How soon before surgery in carcinoid tumor pt should you start ocreotide?
2 weeks
358
2 diagnostic tests before carcinoid tumor surgery?
x ray to eval extraintestinal manifestations, Echo to diagnose right sided heart disease
359
2 examples of serotonin antagonists are?
ocreotide and somatostatin
360
What's the 1/2 life and dose of ocreotide?
100 min; 100 mg SQ 2-3 times daily
361
How does Sandostatin/ocreotide work?
inhibits all bioactive substances
362
1/2 life of somatostatin?
2-3 min
363
Type of medication for carcinoid syndrome which is an inhibitory peptide to antagonize and suppress the release of tumor products?
stomatostatin
364
How does somatostatin work?
it binds to receptors of tumor cells and results in decreased secretion
365
Be ready to treat what 4 things during surgery for pt with carcinoid syndrome?
decreased peripheral vascular resistance, hypotension, bronchospasm, HTN
366
What pressor should you use for refractory hypotension in pt with carcinoid syndrome?
vasopressin
367
Avoid histamine releasing substances such as what 3 meds during carcinoid syndrome surgery?
morphine, cisatracurium, suxxs
368
3 meds that are good to give during carcinoid syndrome surgery?
steroids, H2 blockers, ocreotide
369
Is spinal anesthetic ok for carcinoid syndrome surgery?
yes
