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Coexisting diseases > Adrenal Disease > Flashcards

Adrenal Disease Flashcards

1
Q
  1. Adernal Cortex: contains which 3 hormones?

2. Adrenal Medulla: contains which 2 hormones/substances?

A
  1. glucocorticoids, mineralocorticoids, androgens

2. epinephrine (80%) and NE (20%)

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2
Q

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)

A
  • protein turnover
  • fat metabolism
  • cardiovascular tone
  • stress
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3
Q

– Hyperadrenocorticism = ?
– Hyperaldosteronism = ?
– Hypoadrenocorticism = ?

A
  • Cushing’s Disease
  • Conn’s Disease
  • Addison’s Disease
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4
Q

Cushings syndrome-Hypercorticism
●EXCESSIVE _______ SECRETION
–ACTH dependent
●Cushings disease ______ tumors (microadenomas)
●Non endocrine tumors of lung, kidney, or pancreas = ?

A
  • cortisol
  • pituitary corticotroph
  • acute ectopic corticotropin syndrome
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5
Q

Cushings syndrome-Hypercorticism
●EXCESSIVE CORTISOL SECRETION
–ACTH independent
●Benign or malignant _____ tumors

A
  • adrenocortical
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6
Q

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, ______

A
  • HTN
  • glucose intolerance
  • osteoporosis
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7
Q

Diagnosis and Treatment of Cushings:
Diagnosis: Treatment:
* urine and plasma ____ *surgical =
* plasma levels of ____ 1. transphenoidal ____
2. ______
*irradiation

A
  • cortisol levels 1. microadenectomy

* ACTH 2. adrenalectomy

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8
Q 
Cushings: Anesthetic Management Considerations
●Preop evaluation, Positioning
●Skeletal \_\_\_\_\_
●\_\_\_\_, Blood Loss
●Choice of agents
A
  • muscle weakness

* cortisol

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9
Q 
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)]
A
  • hypokalemia, hypernatremia
  • metabolic alkalosis
  • diabetes
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10
Q

Cushings Anesthetic Management: Positioning
●__ and __- vertebral compression fractures
●____, Use appropriate padding
●Check position throughout case
●Care when moving to stretcher use of roller

A
  • osteoporosis and osteomalacia

* obesity

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11
Q

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

A
  • hypokalemia
  • muscle relaxants
  • 1 twitch
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12
Q

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

A
  • glucocorticoid
  • intraoperatively
  • 3-6 days
  • mineralcorticoid
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13
Q 
Cushings Anesthetic Management: Blood Loss
●May be significant
●Type and Screen
●Major surgery- \_\_\_\_\_
●CVP/Swan
●\_\_\_\_
A
  • type and cross

* Aline

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14
Q

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 ______.

A
  • decrease cortisol
  • stress and ACTH
  • Etomidate
  • insignificant, surgical stress
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15
Q 
Cushings Anesthetic Management: Complications
●Transphenoidal microadenomectomy
       –\_\_\_   –Transient \_\_\_\_\_    –\_\_\_\_
●Adrenalectomy
      – Laparoscopic: ●Position   ●\_\_\_
–Open = ●Higher incidence of \_\_\_
A
  • VAE, transient diabetes insipidius, meningitis
  • insufflation
  • pneumothorax
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16
Q

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)

A
  • aldosterone, functional tumor

* serum renin, aldosterone

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17
Q

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, ___)

A
  • HTN
  • Na retention, fluid retention
  • Hypokalemia, metabolic alkalosis
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18
Q

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.

A
  • spirnolactone
  • potassium (K+)
  • vasodilators/diuresis
  • cortisol
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19
Q

Addison’s Disease
● Primary Adrenal Insufficiency
–Idiopathic
–No symptoms until ___ of adrenal ___ has been destroyed
● Deficiency of all adrenal cortex secretions (???)

A
  • 90%, adrenal cortex

* mineralcorticoids, glucocorticoids, and androgens

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20
Q

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

A
  • hypotension
  • BUN, hypovolemia
  • Hyperkalemia, Hyponatremia, Hypoglycemia
  • Hyperpigmentation
21
Q

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

A
  • 20
  • ACTH
  • greater than 25
  • ACTH
22
Q

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

A
  • increased dose
  • Hypoglycemia
  • cortisol 100mg IV
  • colloid
  • inotropic
23
Q 
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)
A
  • arthritis
  • asthma
  • 1 month
24
Q

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)

A
  • exogenous corticosteroids
  • 25 mg (minor surgery)
  • 100mg (cont infusion - major surgery)
  • 8 hours
25
Q

Adrenal Glands
●Located just above each kidney
●Two portions:
– ___ 80-90% (zona glomerulosa, fasciculata, reticularis) & ___ 10-20%
●Complex regulation (Hypothalamus, Anterior pituitary, Adrenal Cortex)

A
  • cortex

* medulla

26
Q

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

A
  • shock
  • vasopressor
  • cortisol 100mg
27
Q

Addison’s-Anesthetic Management Considerations
●Measure ___ levels preop and every hour
●Hypoglycemia- replace with dextrose solutions
●Check electrolytes frequently -___ levels a concern (avoid ___)

A
  • glucose

* K, avoid LR

28
Q

Addison’s-Anesthetic Management Considerations
●Avoid ___!
●Inhalation Agents— sensitive to drug induced ___
●PNS- titrate muscle relaxants due to ___

A
  • Etomidate
  • myocardial depression (nitrous, enflurane, halothane)
  • skeletal muscle weakness
29
Q

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

A
  • hyporeninemia
  • angiotensin stimulation
  • inhibit renin release
30
Q

Hypoaldosteronism Signs/symptoms and Treatment
Signs and Symptoms: Treatment:
●___ acidosis 1. mineralocorticoids - ?
●Severe hyperkalemia 2. liberal ___
● (Na?)
●Myocardial ____ defects

A
  • Hyperkalemic 1. fludrocortisone
  • Hyponatremia 2. Na intake
  • conduction
31
Q

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

A
  • catecholamine
  • adrenal medulla
  • abdominal cavity
32
Q

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

A
  • HTN
  • headache, palpitations
  • orthostatic hypotension
  • anxiety
33
Q 
Diagnosis for Pheochromcytoma
●Urine tests : Unreliable
●Plasma levels
–Reliably reflects the presence of Pheo
–Measure plasma free \_\_\_
●Radiographic tests to locate tumor: CT/MRI
A
  • metanephrines
34
Q

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- ___

A
  • Phenoxybenzamine (alpha 1 and 2) or Prazosin (select alpha 1)
  • Insulin
  • Beta block (esmolol)
35
Q

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

A
  • beta block
36
Q

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

A
  • PVR
  • cerebral
  • hyperglycemia
37
Q

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.

A
  • 165/90
  • 80/45
  • 1 PVC
38
Q

Pheochromocytoma: Anesthetic Considerations
●Good communication with surgeon
●Continue ____ ●Fluid management
–Hypovolemic- Prehydrate
–Falsely ____: Type and Cross –?Renal function
–Fluid Replacement Plan!! (4/2/1)

A
  • adrenergic blockade

* elevated HCT

39
Q

Pheochromocytoma: Anesthetic Considerations
●Heavy premedication- ______ ●Gentle positioning
●Anesthetic technique
–Combined ___ /Continuous ____
–Epidural prior to ____ –Invasive monitoring

A
  • benzos and opioids
  • GA with cont lumbar epidural
  • induction
40
Q

Pheochromocytoma: Anesthetic Considerations-Monitors
● EKG ●____- BP Control, ABGs, Electrolytes, Glucose levels
●Swan ganz/ ?TEE ●CVP ●____
● Temperature
● Peripheral Nerve Stimulator

A
  • Aline

* UOP

41
Q 
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
A
  • lidocaine
  • histamine release
  • sufentanil
  • propofol
42
Q

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

A
  • IA
  • lidocaine
  • opioid, SNS stim
  • Nitroprusside
  • Phentolamine, Esmolol
43
Q

Pheochromocytoma: Anesthetic Considerations-Intra op
●Inhalation agent for Maintenance- ?/?/?
●____ MAC more control than opioid technique
●Combined technique with ____
●Opioid
●Muscle relaxant-?/?

A
  • N2O/O2/ des or sevo
  • 1.5-2 MAC
  • epidural
  • roc and vec
44
Q

Pheochromocytoma: Anesthetic Considerations
●Blood pressure control
* ___ -preferred *____- tachyphylaxis, tachycardia & longer duration
* ___-histamine release
●Heart rate control-Beta blockade
*Propranolol *___-preferred *Labetalol

A
  • NTP
  • Phentolamine
  • Trimethaphan
  • Esmolol
45
Q

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

A
  • decrease catecholamines
  • IAs
  • Volume (first! - crystalloids/colloids)
  • Phenylephrine, norepinephrine, dopamine
  • RA/GA
  • NE
46
Q

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

A
  • morphine, atracurium
  • Halothane
  • Succs, catechols from tumor
  • Droperidol
47
Q

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

A
  • cont lumbar epidural
  • 10 days
  • early
48
Q

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

A
  • hypoglycemia
  • steroid
  • occult tumors

Coexisting diseases (8 decks)

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