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N935 Advanced Pathophysiology II > Adrenal Disease > Flashcards

Adrenal Disease Flashcards

1
Q

adrenal glands

A
  • multifunctional and secrete variety of hormones

- located just above each kidney

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2
Q

two portions of adrenal gland

A
  • cortex (80-90%)

- medulla (10-20%)

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3
Q

three zones of adrenal cortex

A
  • zona glomerulosa (aldosterone)
  • zona fasciculata (cortisol)
  • zona reticularis (androgens)
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4
Q

adrenal cortex hormones

A
  • glucocorticoids (cortisol)
  • mineralocorticoids (aldosterone)
  • androgens
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5
Q

adrenal medulla hormones

A
  • epi (80%)

- NE (20%)

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6
Q

cortisol functions

A
  • blood glucose regulation
  • protein turnover
  • fat metabolism
  • sodium, potassium, calcium balance
  • maintenance of CV tone
  • modulation of tissue response to injury or infection
  • survival as result of stress
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7
Q

hypercortisolism (cushings)

A
  • excessive cortisol secretion

- can be ACTH dependent or ACTH independent

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8
Q

ACTH dependent

A
  • cushings disease pituitary corticotroph tumors (microadenomas)
  • non-endocrine tumors of lung, kidney or pancreas (ectopic corticotrophin syndrome)
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9
Q

ACTH independent

A
  • primary disease involving the gland itself

- benign or malignant tumors

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10
Q

cushings S/S

A
  • sudden weight gain (central)
  • thickening of facial fat (moon)
  • lyte abnormalities
  • systemic HTN
  • glucose intolerance
  • menstrual irregularities
  • decreased libido
  • skeletal muscle wasting
  • depression/insomnia
  • osteoporosis
  • hypercoagulable
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11
Q

diagnosis of cushings

A
  • plasma and urine cortisol levels
  • CRH stimulation test
  • dexamethasone suppression test
  • inferior petrosal sinus sampling (IPSS)
  • CT and MRI once diagnosis confirmed
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12
Q

cushings treatment

A
  • surgical

- irradiation

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13
Q

cushings anesthetic considerations

A
  • preop eval
  • positioning
  • skeletal muscle weakness
  • cortisol
  • blood loss
  • choice of agents
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14
Q

cushings preop considerations

A
  • HTN
  • intravascular volume
  • lytes -hypokalemia, hypernatremia
  • acid base status (hypokalemic metabolic acidosis
  • cardiac compromise -CHF
  • DM check glucose
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15
Q

cushings anesthetic positioning considerations

A
  • osteoporosis and osteomalacia (vertebral compression fractures)
  • obesity
  • use appropriate padding
  • check position during case
  • care when moving to stretcher use of roller
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16
Q

cushings anesthetic management of muscle weakness

A
  • hypokalemia = contributing factor (treat preop)
  • decreased requirement for muscle relaxant
  • use PNS
  • maintain 1 twitch if possible
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17
Q

cushings anesthetic management of cortisol

A
  • 100 mg glucocorticoid (hydrocort)/24 hours start in OR
  • dose tapered over 3-6 days to maintenance
  • mineralocorticoid may also need supplementation
  • unilateral = may not require continued therapy
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18
Q

cushings anesthetic considerations blood loss

A
  • may be significant
  • t&s
  • major surgery = t&c
  • CVP and ALINE
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19
Q

cushings anesthetic management anesthetic agents

A
  • some inhalation agents depress adrenal response to stress and ACTH
  • etomidate - inhibits 11 Beta hydroxylase (involved in cortisol and aldosterone synthesis) = adrenocortical suppression if long term infusion
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20
Q

cushings anesthetic management complications

A

-transphenoid microadenomectomy - VAE, DI, meningitis

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21
Q

conn’s syndrome

A
  • primary hyperaldosteronism
  • excessive secretion of aldosterone from functional tumor
  • occurs more in women than men; rare in kids
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22
Q

secondary hyperaldosteronism

A

-increased circulating serum renin stimulates release of aldosterone (renovascular hypertension)

23
Q

Conn’s disease S/S

A
  • nonspecific, some asymptomatic
  • systemic HTN (HA, DBP 100-125); may be resistant to treatment
  • hypokalemia (skeletal muscle cramps, skeletal muscle weakness, metabolic alkalosis)
24
Q

anesthetic management of hyperaldosteronism

A
  • correct decreased K and HTN
  • assess cardiac/renal status
  • avoid hyperventilation (further decreases K)
  • monitors include A line
  • adequate fluids with vasodilators/diuresis
  • check acid/base and lytes often
  • exogenous cortisol 100 mg/q 24 hours
25
Q

addison’s disease

A
  • primary adrenal insufficiency
  • idiopathic/autoimmune
  • no symptoms until 90% adrenal cortex destroyed
  • deficiency of all adrenal cortex secretions = mineralocorticoids, glucocortiocoids, androgens
26
Q

addison’s disease S/S

A
  • chronic fatigue
  • muscle weakness
  • hypotension
  • weight loss
  • anorexia N/V/D
  • increased BUN + hemoconcentration
  • hyponatremia
  • hyperkalemia
  • hypoglycemia
  • abd or back pain
  • hyperpigmentation in sun exposed areas to distal extremities
27
Q

addison’s disease diagnosis

A
  • baseline plasma cortisol of <20
  • cortisol level <20 after ACTH stimulation test
  • NORMAL response is cortisol level >25
28
Q

addisonian crisis

A
  • triggered in steroid dependent who do not receive increased dose during stress
  • stress –> circulatory collapse (hypoglycemia, lyte imbalance, depressed mentation)
29
Q

addisonian crisis treatment

A
  • IV cortisol 100 mg Q4-6H
  • D5NS
  • volume colloid
  • whole blood
  • inotropic support
30
Q

exogenous steroids in addison’s before surgery

A
  • take daily dose DOS
  • minor surgery - 25 mg hydrocort
  • major surgery - 100 mg bolus followed with infusion at 10 mg/hr OR 100 mg Q6H
31
Q

addisons intraop hypotension management

A
  • rule out usual causes of shock
  • measure CVP, SSV or PPV –> give fluids if indicated
  • treatment - vasopressor, cortisol admin (100mg), fluids, invasive monitoring
32
Q

addison’s other anesthetic considerations

A
  • measure BG often (q1h intraop)
  • hypoglycemia - dextrose solution
  • check lytes often
  • avoid etomidate
  • inhalation agents - sensitive to drug induced myocardial depression
  • PNS - titrate muscle relaxants d/t skeletal muscle weakness
33
Q

hypoaldosteronism

A
  • congenital deficiency
  • hyporeninemia - due to long standing DM and renal failure and/or tx with ACE-i (loss of ANG stimulation)
  • nonsteroidal inhibitors of prostaglandin synthesis
34
Q

hypoaldosteronism s/s

A
  • hyperkalemic acidosis
  • severe hyperkalemia
  • hyponatremia
  • myocardial conduction defects
35
Q

hypoaldosteronism treatment

A
  • mileralocorticoids (fludrocortisone)

- liberal sodium intake

36
Q

pheochromocytoma

A
  • catechol secreting tumor
  • originates in adrenal medulla and related tissues elsewhere in body
  • 95% found in abd cavity
  • 90% in adrenal medulla
  • 10% involve both glands
  • most common in young to mid adult live (30s-50s)
37
Q

pheochromocytoma predominant symptoms

A
  • HTN continuous or paroxysmal
  • HA
  • diaphoresis/pallor
  • palpitations/tachycardia
38
Q

pheochromocytoma associated symptoms

A
  • orthostatic hypotension
  • anxiety
  • tremor
  • chest pain
  • epigastric pain
  • flushing
  • painless hematuria
39
Q

pheochromocytoma episodes timing

A
  • duration - one hour or less

- frequency -daily to once every few months

40
Q

pheochromocytoma diagnosis

A
  • urine test (screening but not good for definitive diagnosis)
  • plasma levels (reliable reflection of presence of pheo); measure plasma free metanephrines (breakdown products of epi and NE)
  • radiographic tests to locate tumor
41
Q

metanephrine levels in pheo

A
  • normetanephrine >400

- metanephrine >220

42
Q

pheochromocytoma treatment

A
  • surgical excision = definitive treatment
  • test = phenoxybenzamine or prazosin to produce alpha block
  • restore intravascular volume
  • restore release of insulin with alpha block
  • persistant tachy-beta block (esmolol)
  • DO NOT give non-selective beta block in absence of alpha block (unable to maintain CO)
43
Q

pheochromocytoma preop considerations

A
  • optimization
  • history and labs
  • increased PVR –> myocardial ischemia, ventricular hypertrophy, CHF, cardiomyopathy
  • hx cerebral hemorrhage
  • hyperglycemia
44
Q

pheochromocytoma preop criteria

A
  • no BP >165/90 for 48 hours before surgery
  • BP on standing should not be <80/45
  • ECG without ST-T wave changes
  • no more than 1 PVC Q5min
45
Q

pheochromocytoma anesthetic considerations

A
  • good communication with surgeon
  • continue adrenergic blocks
  • fluid management
  • heave premed with benzos and opioids
  • gentle positioning (bc compression can cause release of catechols)
46
Q

pheochromocytoma anesthetic technique

A
  • combined GA/continuous labor epidural
  • epidural prior to induction
  • invasive monitoring
47
Q

pheochromocytoma anesthetic considerations induction

A
  • prepare for hyperdynamic BP
  • lido 1-2 mg/kg
  • no mso4 - histamine release can stimulate release of catechols
  • sufenta - 0.5-1 mcg/kg
  • fent - 3-5 mcg/kg
  • prop - 3 mg/kg
48
Q

pheochromocytoma intraop considerations

A
  • inhalation agent for maintenance (des and sevo)
  • 1.5-2 MAC more control than opioid technique
  • combined technique with epidural
  • opioid
  • muscle relaxation (vec/roc)
49
Q

pheochromocytoma blood pressure control intraop

A
  • nitroprusside (preferred)
  • phentolamine
  • mag sulfate
  • calcium channel blockers
50
Q

pheochromocytoma heart rate control

A
  • beta blockade
  • esmolol = best
  • labetalol
  • metoprolol
51
Q

surgical ligation of pheo’s venous drainage causes what?

A
  • decreased catechols - hypotension
  • stop antihypertensives
  • decreased inhalation agent
  • volume FIRST
  • then pressors - phenyl, NE, dopa
  • combined regional and GA will decrease hypotension
  • persistant hypotension = may require NE infusion until body can adapt to decreased level of alpha stim
52
Q

pheochromocytoma drugs to avoid

A
  • histamine releasers (MSO4, atracurium)
  • halothane -sensitizes myocardium to epi
  • succ -fasiculations of abd muscles may release catechols
  • panc and atropine
  • metoclopramide (catechol release in pheo via stimulation of 5HT4 receptors on surface of pheo)
53
Q

pheochromocytoma post op considerations

A
  • analgesia - CLE, PCA, opioids
  • 50% patients remain hypertensive
  • early extubation
  • hypoglycemia
  • steroid supplementation
  • post op HTN (presence of other tumors, vol overload, continue to monitor)
  • adequate pain control

N935 Advanced Pathophysiology II (16 decks)

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