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
