Adrenal Disease Flashcards
- Adernal Cortex: contains which 3 hormones?
2. Adrenal Medulla: contains which 2 hormones/substances?
- glucocorticoids, mineralocorticoids, androgens
2. epinephrine (80%) and NE (20%)
Adrenal Glands wide variety of physiological functions.
●Blood glucose regulation, _____ turnover, ______
●Sodium, potassium, and calcium balance, maintenance of __ tone
●Modulation of tissue response to injury or infection
●Survival as a result of _____ (most important)
- protein turnover
- fat metabolism
- cardiovascular tone
- stress
– Hyperadrenocorticism = ?
– Hyperaldosteronism = ?
– Hypoadrenocorticism = ?
- Cushing’s Disease
- Conn’s Disease
- Addison’s Disease
Cushings syndrome-Hypercorticism
●EXCESSIVE _______ SECRETION
–ACTH dependent
●Cushings disease ______ tumors (microadenomas)
●Non endocrine tumors of lung, kidney, or pancreas = ?
- cortisol
- pituitary corticotroph
- acute ectopic corticotropin syndrome
Cushings syndrome-Hypercorticism
●EXCESSIVE CORTISOL SECRETION
–ACTH independent
●Benign or malignant _____ tumors
- adrenocortical
Cushings signs and symptoms
●Sudden weight gain (usually central), thickening of the facial fat (“moon face”)
●Electrolyte abnormalities, Systemic _____ , _______
●Menstrual irregularities, Decreased libido, Skeletal muscle wasting
●Depression and insomnia, ______
- HTN
- glucose intolerance
- osteoporosis
Diagnosis and Treatment of Cushings:
Diagnosis: Treatment:
* urine and plasma ____ *surgical =
* plasma levels of ____ 1. transphenoidal ____
2. ______
*irradiation
- cortisol levels 1. microadenectomy
* ACTH 2. adrenalectomy
Cushings: Anesthetic Management Considerations ●Preop evaluation, Positioning ●Skeletal \_\_\_\_\_ ●\_\_\_\_, Blood Loss ●Choice of agents
- muscle weakness
* cortisol
Cushings: Preoperative Considerations ●HTN, Intravascular volume ●Electrolytes- \_\_\_\_; \_\_\_\_\_\_ ●Acid-Base status- hypokalemic \_\_\_\_\_ ●Cardiac compromise-CHF ● \_\_\_\_-check glucose level [(Control with small amounts of IV insulin (1-5 units q hour)]
- hypokalemia, hypernatremia
- metabolic alkalosis
- diabetes
Cushings Anesthetic Management: Positioning
●__ and __- vertebral compression fractures
●____, Use appropriate padding
●Check position throughout case
●Care when moving to stretcher use of roller
- osteoporosis and osteomalacia
* obesity
Cushings Anesthetic Management: Muscle Weakness
● _____-contributing factor. (Treat Pre-op 80-100mEq/day oral)
●Decreased requirements for ___
●USE a Peripheral Nerve Stimulator (PNS)
●Maintain ___ if possible
- hypokalemia
- muscle relaxants
- 1 twitch
Cushings Anesthetic Management: Cortisol
●Unilateral or bilateral adrenalectomy
–100mg _____/24 hrs usually started ____
–Dose reduced over ____ to maintenance dose
–______ may also need supplementation
–Unilateral continued therapy may not be required depending upon remaining gland
- glucocorticoid
- intraoperatively
- 3-6 days
- mineralcorticoid
Cushings Anesthetic Management: Blood Loss ●May be significant ●Type and Screen ●Major surgery- \_\_\_\_\_ ●CVP/Swan ●\_\_\_\_
- type and cross
* Aline
Cushings Anesthetic Management: Anesthetic Agents
●Drugs or techniques not likely to influence attempts to ___ levels
–Some inhalation agents depress adrenal response to _____
–_____- inhibits enzymes involved in cortisol and aldosterone synthesis. Long term infusion- adrenocortical suppression.
●Changes caused by anesthetic agent or type are ____ when
compared to increase in cortisol secretion with ______.
- decrease cortisol
- stress and ACTH
- Etomidate
- insignificant, surgical stress
Cushings Anesthetic Management: Complications
●Transphenoidal microadenomectomy
–\_\_\_ –Transient \_\_\_\_\_ –\_\_\_\_
●Adrenalectomy
– Laparoscopic: ●Position ●\_\_\_
–Open = ●Higher incidence of \_\_\_- VAE, transient diabetes insipidius, meningitis
- insufflation
- pneumothorax
Primary Hyperaldosteronism (Conn’s Syndrome)
●Excess secretion of ____ from a ____
●Occurs more in women than men
●Secondary Hyperaldosteronism
- Increased circulating _____stimulates the release of _____
(renovascular hypertension)
- aldosterone, functional tumor
* serum renin, aldosterone
Conn’s disease Signs and Symptoms
●Non specific and some are asymptomatic
●Systemic ____ (headache, diastolic BP 100-125 mmHg) reflects aldosterone induced ____ and resulting increased ____.
MAY BE RESISTANT TO TREATMENT
* _____ (skeletal muscle cramps, skeletal muscle weakness, ___)
- HTN
- Na retention, fluid retention
- Hypokalemia, metabolic alkalosis
Anesthesia Management Hyperaldosteronism
●Correct decreased K+ and HTN ( ____ )
●Assess cardiac/renal status
●Avoid hyperventilation - further decreases __
●Monitors: A-line, swan, Adequate fluids w/ ____
●Check acid-base, electrolytes frequently
●Exogenous ____ 100 mg/q 24 hr.
- spirnolactone
- potassium (K+)
- vasodilators/diuresis
- cortisol
Addison’s Disease
● Primary Adrenal Insufficiency
–Idiopathic
–No symptoms until ___ of adrenal ___ has been destroyed
● Deficiency of all adrenal cortex secretions (???)
- 90%, adrenal cortex
* mineralcorticoids, glucocorticoids, and androgens
Addison’s Disease Signs and Symptoms
●Chronic fatigue, Muscle weakness
●BP (___?), Wt. loss, Anorexia, N/V and diarrhea
●Increased ____ and Hemoconcentration due to ___
* Electrolyes (Na and K) and glucose?
●Abdominal or back pain
●______ in sun-exposed areas and the distal extremities
- hypotension
- BUN, hypovolemia
- Hyperkalemia, Hyponatremia, Hypoglycemia
- Hyperpigmentation
Diagnosis: Addison’s Disease
●Baseline plasma cortisol level less than __ ug/dl
* Cortisol level less then 20ug/dl after ___ stimulation test
* Cortisol levels measured 30 and 60 minutes following admin of ACTH
* normal response is a plasma cortisol level ___
* positive test yields a poor response to ____ and is indicative of adrenal cortex impairment
- 20
- ACTH
- greater than 25
- ACTH
Addisonian Crisis
●Triggered in steroid-dependent who do not receive ___ during stress
●Stress - Circulatory Collapse
- _____, Electrolyte imbalance, Depressed mentation
●Rx: IV ___ q 4-6 hr. for 24 hrs.; D5 0.9%NS; Volume- __, whole blood
●___ support
- increased dose
- Hypoglycemia
- cortisol 100mg IV
- colloid
- inotropic
Footnote…Steroid Replacement in general ●When: ANY Patient is on steroids – \_\_\_? – \_\_\_? –Steroid creams (rash, poison ivy) –if treated for \_\_\_ in last 6-12 months (12 mos. to recover after stopped)
- arthritis
- asthma
- 1 month
Addison’s-Anesthetic Management Considerations:
●Administer ____
●If on a daily dose- SHOULD TAKE day of surgery
●Recommended dose for surgery: ____ hydrocortisone for minor sx
Major surgery:
– 25mg + ___ con’t infusion over 24 hr; OR
–100mg every ____ ( 100mg preop + 100mg intraop + 100mg. Postop)
- exogenous corticosteroids
- 25 mg (minor surgery)
- 100mg (cont infusion - major surgery)
- 8 hours
Adrenal Glands
●Located just above each kidney
●Two portions:
– ___ 80-90% (zona glomerulosa, fasciculata, reticularis) & ___ 10-20%
●Complex regulation (Hypothalamus, Anterior pituitary, Adrenal Cortex)
- cortex
* medulla
Addison’s-Anesthetic Management Considerations
●Intraoperative Hypotension
–Rule out usual causes of ___, Measure CVP- fluids
●Hypotension Rx
–_____- even if did not have effect before cortisol
–Administer ___ mg IV, Fluids, Invasive monitoring
- shock
- vasopressor
- cortisol 100mg
Addison’s-Anesthetic Management Considerations
●Measure ___ levels preop and every hour
●Hypoglycemia- replace with dextrose solutions
●Check electrolytes frequently -___ levels a concern (avoid ___)
- glucose
* K, avoid LR
Addison’s-Anesthetic Management Considerations
●Avoid ___!
●Inhalation Agents— sensitive to drug induced ___
●PNS- titrate muscle relaxants due to ___
- Etomidate
- myocardial depression (nitrous, enflurane, halothane)
- skeletal muscle weakness
Hypoaldosteronism
●Congenital deficiency ●______
–Due to long standing diabetes and renal failure and/or treatment with ace inhibitors -loss of _____
●Nonsteroidal inhibitors of prostaglandin synthesis
–May __ release and exacerbate condition in presence of renal insufficiency
- hyporeninemia
- angiotensin stimulation
- inhibit renin release
Hypoaldosteronism Signs/symptoms and Treatment
Signs and Symptoms: Treatment:
●___ acidosis 1. mineralocorticoids - ?
●Severe hyperkalemia 2. liberal ___
● (Na?)
●Myocardial ____ defects
- Hyperkalemic 1. fludrocortisone
- Hyponatremia 2. Na intake
- conduction
Pheochromocytoma
●____ -secreting tumor ●Originates in the ____ and related tissues
elsewhere in the body
– greater than 95% found in ___? – about 90% originate in adrenal medulla – About 10% involve both adrenal glands
- most common in young to mid adult life
- catecholamine
- adrenal medulla
- abdominal cavity
Pheochromocytoma : Predominant Symptoms
●___ continuous or paroxysmal, ____, Diaphoresis/Pallor, _____/Tachycardia
–Associated Symptoms
●___ hypotension, ___, Tremor, Chest Pain, Epigastric Pain, Flushing, Painless Hematuria
–Timing of episodes
●Duration: One hour or less, Frequency: daily to once every few months
- HTN
- headache, palpitations
- orthostatic hypotension
- anxiety
Diagnosis for Pheochromcytoma ●Urine tests : Unreliable ●Plasma levels –Reliably reflects the presence of Pheo –Measure plasma free \_\_\_ ●Radiographic tests to locate tumor: CT/MRI
- metanephrines
Rx Pheochromocytoma
●Surgical excision
●Test: __ (alpha 1&2) or __ (selective alpha 1) to produce alpha block
●Restore intravasc volume - decrease Hct evident
●Restore release of ___ w/ ALPHA block
●Persistant Tachy- ___
- Phenoxybenzamine (alpha 1 and 2) or Prazosin (select alpha 1)
- Insulin
- Beta block (esmolol)
Rx Pheochromocytoma
●DO NOT administer non selective ____ in absence of alpha-block-heart depressed by beta block unable to maintain C.O. w/unopposed alpha mediated vasoconstriction
- beta block
Pheochromocytoma: Pre op Considerations
●Optimize the pre op patient condition
●Preoperative visit- History & Labs
–Increased ___->Myocardial ischemia, ventricular hypertrophy, CHF, cardiomyopathy -Hx ___ hemorrhage
– ____-decreased circulating insulin with increased glycogenolysis
- PVR
- cerebral
- hyperglycemia
Pheochromocytoma: Pre op criteria
●No BP reading greater than ____ for 48 hrs. prior to surgery
●BP on standing should not be less than ___
●ECG without ST-T wave changes that are not permanent
●No more than ___ q 5 min.
- 165/90
- 80/45
- 1 PVC
Pheochromocytoma: Anesthetic Considerations
●Good communication with surgeon
●Continue ____ ●Fluid management
–Hypovolemic- Prehydrate
–Falsely ____: Type and Cross –?Renal function
–Fluid Replacement Plan!! (4/2/1)
- adrenergic blockade
* elevated HCT
Pheochromocytoma: Anesthetic Considerations
●Heavy premedication- ______ ●Gentle positioning
●Anesthetic technique
–Combined ___ /Continuous ____
–Epidural prior to ____ –Invasive monitoring
- benzos and opioids
- GA with cont lumbar epidural
- induction
Pheochromocytoma: Anesthetic Considerations-Monitors
● EKG ●____- BP Control, ABGs, Electrolytes, Glucose levels
●Swan ganz/ ?TEE ●CVP ●____
● Temperature
● Peripheral Nerve Stimulator
- Aline
* UOP
Pheochromocytoma: Anesthetic Considerations-Induction
●Prepare for hyperdynamic BP
– \_\_\_\_ (1 to 2 mg/kg)
–Opioid (No MSO4- \_\_\_\_)
●\_\_\_\_ (0.5 to 1 ug/kg)
●Fentanyl (3 to 5 ug/kg)
– \_\_\_\_ 3mg/kg- lidocaine
- histamine release
- sufentanil
- propofol
Pheochromocytoma: Anesthetic Considerations Laryngoscopy
●Must have adequate depth- ____ to deepen
●____ IV 1-2 mg/kg 1 min before
●____: fentanyl and sufentanil to attenuate ___ ●___ 1-2 ug/kg
●___- alpha blocker ● ___ - beta blocker
●AVOID release histamine
- IA
- lidocaine
- opioid, SNS stim
- Nitroprusside
- Phentolamine, Esmolol
Pheochromocytoma: Anesthetic Considerations-Intra op
●Inhalation agent for Maintenance- ?/?/?
●____ MAC more control than opioid technique
●Combined technique with ____
●Opioid
●Muscle relaxant-?/?
- N2O/O2/ des or sevo
- 1.5-2 MAC
- epidural
- roc and vec
Pheochromocytoma: Anesthetic Considerations
●Blood pressure control
* ___ -preferred *____- tachyphylaxis, tachycardia & longer duration
* ___-histamine release
●Heart rate control-Beta blockade
*Propranolol *___-preferred *Labetalol
- NTP
- Phentolamine
- Trimethaphan
- Esmolol
Pheochromocytoma: Anesthetic Considerations-Intraop BP control
●With surgical ligation of tumor’s venous drainage = ____ -prepare for hypotension ●Stop antiHTN ●Decrease concentration ___
●___ first! ●Administer pressors: (3)
●Combined ___ decreases hypotension-Adeq preop volume replaced
●Persistent hypotension may require an infusion of ___ until the vasculature can adapt to dec. levels alpha stimulation
- decrease catecholamines
- IAs
- Volume (first! - crystalloids/colloids)
- Phenylephrine, norepinephrine, dopamine
- RA/GA
- NE
Pheochromocytoma: Drugs to Avoid
●Histamine releasers- ??
●____ - sensitizes myocardium to epinephrine
●_____ -fasciculations of abd muscles may cause release of ___
●____ - HTN due to antagonism of presynaptic DA receptors which normally inhibit catechol release
● Metoclopramide
- morphine, atracurium
- Halothane
- Succs, catechols from tumor
- Droperidol
Pheochromocytoma: Postoperative Considerations
●Analgesia
*___ *PCA *opioids
●50% of patients will remain HTN
*Elevated catechole levels for ___ postop *Continue antiHTN tx
● ___ extubation –young, no lung involvement
- cont lumbar epidural
- 10 days
- early
Pheochromocytoma: Postoperative Considerations
●___ :excess insulin release and ineffective lipolysis and glycogenolysis
●_____ supplementaion
*Bilat adrenalectomies or hypoadrenalism
●Postoperative HTN : *Presence of ___ *Volume overload
*Continue monitoring
●Adequate pain control
- hypoglycemia
- steroid
- occult tumors
