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N935 Pathophysiology > Adrenal Glands > Flashcards

Adrenal Glands Flashcards

1
Q

What has multiply functions & secretes a variety of hormones?

A

adrenal glands

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2
Q

What are the size of the adrenal glands?

A

no larger than a walnut and weighs less then a grape

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3
Q

What are the two portions of each adrenal glands?

A

cortex

medulla

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4
Q

What does the adrenal cortex?

A

80-90% glands
zona glomerulosa: glucocorticoids (cortisol)
zona fasciculata: mineralocorticoids (aldosterone)
zona reticularis: Androgen (sex hormones)
outer aspect

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5
Q

What is the adrenal medulla

A

10-20% inner portion
epinephrine 80%
Norepinephrine 20%

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6
Q

How much blood flow do the adrenal glands receive?

A

one of the highest rates of blood flow per gram of tissue

separate blood flow from the kidneys

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7
Q

Describe the regulation of adrenal glands?

A

complex regulation
hypothalamus, anterior pituitary
adrenal cortex
Hypothalamus-> CRH-> pituitary gland-> ACTH->adrenal gland-> cortisol

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8
Q

What are the eight physiological functions of the adrenal glands?

A

blood glucose regulation
protein turnover
fat metabolsim
sodium, postassium and calcium
maintenance of cardiovascular tone
modulation of tissue response to injury or infection
survival as result of stress (most important)

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9
Q

What is excessive cortisol secretion called?

A

cushing syndrome

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10
Q

What are the two types of cushing syndrome?

A

independent and dependent

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11
Q

What is independent ACTH?

A

benign or malignant adrenocortical tumors

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12
Q

What is dependent ACTH?

A

hyperplasia
cushing disease pituitary corticotroph tumors (microademonas)
non endocrine tumors of lung, kidney, or pancreas
ectopic corticotropin syndrome

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13
Q

What are twelve signs and symptoms of cushing syndrome?

A 
moon face
sudden weight gain
electrolyte abnormalities
systemic hypertension
glucose intolerance (hyperglycemic)
menstrual irregularies
decreased libido
skeletal muscle wasting
depression and insomnia
osteoporosis
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14
Q

How do you diagnosis cushing syndrome?

A 
plasma and urine cortisol levels
urinary 17 hydroxycorticosteroids 24 hour urine collection
plasma cortisol levels
if both elevated-> cushing's syndrome
CRH stimulation test
dexamethasone suppression test
inferior petrosal sinus sampling (IPSS)
ct and mri once diagnosis is confirmed
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15
Q

Surgical treatments for Cushing syndrome

A

transphenoidal microadenectomy
adrenalectomy
irradiation

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16
Q

What are anesthetic considerations for cushings?

A 
pre-operative evaulation 
positioning
skeletal muscle weakness
cortisol
blood loss
choice of agents
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17
Q

What are preoperative considerations for Cushings?

A

HTN
intravascular volume
hypokalemia, hypernatremia
acid-base status : hypokalemic metabolic alkalosis
cardiac compromise CHF d/t BV and HTN
diabetes (check glucose level)
control with small amounts of IV sulin (1-5 units q hour)

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18
Q

Why is positioning important for cushing syndrome patients?

A

osteoporosis and osteomalacia (vertebral compression fractures)
obesity
use of appropriate padding
check position throughout case
care when moving to stretcher and use of roller

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19
Q

What are anesthetic considerations specific to muscle weakness for cushing syndrome patients?

A

hypokalemia contributing factor
decreased requirements for muscle relaxants
use a PNS
maintain 1 twitch if possible

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20
Q

How do you treat preoperatively hypokalemia in cushing syndrome?

A

treat pre-operatively 80-100mEq/day oral

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21
Q

Cortisol managment in Cushing’s syndrome

A

unilateral or bilateral adrenalectomy
100mg glucocorticoid/ 24hours usually started intraoperatively
dose reduced over 3-6 days to maintain dose
mineralcorticoid may also need supplementation
unilateral continued therapy may not be required depending upon remaining gland

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22
Q

Describe blood loss in cushing syndrome?

A 
may be significant
type and screen
major surgery (type and cross)
CVP
Aline
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23
Q

Describe the use of anesthetic agents in cushings

A

drugs or techniques are not likely to influence attempts to decrease cortisol levels
some inhalation agents depress adrenal response to stress and acth
changes caused by anesthetic agent or type are insignificant when compared to increase in cortisol secretion with surgical stress

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24
Q

What occurs with etomidate?

A

inhibits enzymes involved in cortisol and aldosterone synthesis
long term infusion: adrenocortical suppression

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25
What are complications with transphenodial microadenomectomy?
VAE transient diabetes insipidus meninigitis
26
What are complications with an adrenalectomy (laparoscopic)
position | insufflation
27
What are complications with an adrenalectomy (open)
pulmonary complication nerve injury retraction to keep tissue and organs out of way damage to spleen pancrease and BF to kidney
28
What is primary hyperaldosteroneism?
Conn's syndrome | excess secretion of aldosterone from a functional tumor
29
Who does hyperaldosterone occur in?
women then men
30
What is secondary hyperaldosteronism?
increased circulating serum renin stimulates the release of aldosterone (renovascular hypertension)
31
What are signs and symptoms of COnn's disease?
non specific and asymptomatic Systemic HTN (headache/ diastolic BP 100-125) reflects aldosterone induced sodium retention and resulting increased fluid retention may be resistant to treatment Hypokalemia- skeletal muscle cramps, weakness and metabolic alkalosis Not edematous
32
Describe anesthesia management with hyperaldosteronism?
correct decreased K and HTN (spironolactone) assess cardiac/ renal disease avoid hyperventilation -> further decreases K A line adequate fluids with vasodilators/diuresis check acid-base, electrolytes frequently exogenous cortisol 100mg/24 hr
33
What is addison's disease?
primary adrenal insufficiency idiopathic/autoimmune most common primary cause no symptoms until 90% of adrenal cortex has been destoryed deficiency of all adrenal cortex secretions (mineralcorticoids, glucocorticoids, androgens)
34
What are signs and symptoms of addison's? (11)
``` chronic fatigue muscle weakness hypotension weight loss anorexia, N/V diarrhea increased BUN/ hemoconcentrration due to hypovolemia hyponatremia hyperkalemia hypoglycemia abdominal or back pain hyperpigmentation in sun-exposed areas and distal extremities ```
35
How is addison's disease diagnosed?
baseline plasma cortisol level < 20mcg/dL cortisol levels are measured after 30-60 minutes following ACTH administration normal response to plasma cortisol level >25 mcg/dL positive test results yields poor response to ACTH and is indicative of adrenal cortex impairement
36
What is an addisonian crisis?
triggered in steroid dependent who do not recieve increased dose during stress stress-> circulatory collapse (hypoglycemia, electrolyte imbalance, depressed menatation)
37
What is the treatment for addisonian crisis?
IV cortisol 100mg 4-6h for 24 hours D5 0.9NS volume colloid whole blood intropic support
38
What are anesthetic management considerations for addison's?
administer exogenous corticosteroids take daily dose corticosteroids if prescribed measure glucose levels preop and every hour (replace with dextrose solution) check electrolytes frequently (K levels are concern) avoid LR avoid etomidate inhalation agents (sensitive to drug induced myocardial depression) PNS- titrate muscle relaxants due to skeletal muscles weakness
39
What are the recommended dose for minor surgery with addison's
25mg hydrocortisone
40
What is the recommended dose for major surgery with addison's
100mg bolus followed with infusion 10mg/hr or 100mg every 6hours
41
What are hypotension considerations for addison's?
intraoperatively: rule out usual causes of shock and measure CVP
42
How do you treat hypotension in Addison's?
vasopressor (even if did not have effect before cortisol) administer cortisol 100mg IV fluids invasive monitoring
43
How does hypoaldosteronism occur?
congential deficiency hyporeninemia (due to long standing diabetes and renal failure and/or treatment with ACEi-> loss of angiotensin stimulation) NSAIDs inhibiting prostaglandin synthesis (inhibit renin release and exacerbate condition in presence of renal insufficiency)
44
Signs and symptoms of hypoaldosteronism
hyperkalemic acidosis severe hyperkalemia hyponamtremia myocardial conduction defects
45
What is the treatment for hypoaldosteronism?
mineralcorticoids (fludrocortisone) | liberal sodium intake
46
What is pheochromocytoma
catecholamine secreting tumor
47
where is a pheochromocytoma found?
originated in the adrenal medulla and related tissues elsewhere in the body > 95% found in abdominal cavity 10% found in both adrenal galnds functional tumors in multiple sites are present in 20% of patients especially children
48
When do pheochromocytomas mostly occur?
young to mid adult life
49
What are the predominant symptoms of pheochromocytoma?
HTN continous or paroxysmal headache diaphoresis/pallor palpitation/ tachycardia
50
What are associated symptoms of pheochromocytoma?
``` orthostatic hypotension anxiety tremor chest pain epigatric pain flushing (rare) painless hematuria (rare) ```
51
When is the timing of episodes for pheochromocytoma? | duration and frequency?
duration: one hour or less frequency: daily to once every few months
52
How do you diagnosis a pheochromocytoma?
urine tests plasma levels radiographic test to locate tumor (CT MRI)
53
How do urine tests show pheochromocytoma?
useful for screening but unrelaible for definitive diagnosis
54
how do plasma levels show pheochromocytoma?
reliably reflects the presence of pheo measure plasma free metanephrine normetanephrine > 400pg/ml metanephrine 220pg/ml
55
How do you treat a pheochromocytoma?
surgical excision phenoxybenzamine (alpha 1 and 2) or prazosin (selective alpha 1) to produce alpha blockade restore intravascular volume (decrease Hct evident) restore release of insulin w/ alpha block persistant tachy-beta block (esmolol)
56
What do you not do with pheochromocytoma?
administer beta blocker in absence of alpha block heart depressed by beta block unable to maintain CO with unopposed alpha mediated vasoconstriction
57
What will happen if you beta block then alpha block?
youll decrease the HR with BB and not decrease HR therefore the heart will be pumping against strong afterload causing heart failure
58
What are pre-operative considerations for pheochromocytoma?
optimize the preoperative condition history and labs increased PVR (MI, ventricular hypertrophy, CHF, cardiomyopathy) Hx of cerebral hemorrhage hyperglycemia (decreased circulating insulin with increased glyconeolysis)
59
What are pre-op criteria pheochromocytoma?
No BP reading > 165/90 for 48 hours prior to surgery BP on standing should not be < 80/45 ECG without ST-T wave changes that are not permenant no more then 1 PVC 1 5minutes
60
What are anesethetic considerations for pheochromocytoma?
``` good communication with surgeon continue adrenergic blockade fluid management hypovolemic- prehydrate falsely elevated HCT-> type and cross renal function fluid replacement plan heavy premedication gentle positioning combined GA/ lumbar epidural epidural prior to induction invasive monitoring ```
61
What monitors are required for pheochromocytoma
``` EKG Aline (Bp control, electrolytes, glucose levels TEE CVP UOP temperature PNS ```
62
What should you prepare for with induction of pheochromocytoma?
hyperdynamic BP
63
What is the drug cocktail for pheochromocytoma?
``` lidocaine 1-2 mg/kg opioid (no morphine-histamine release) sufentanil (0.5-1 mcg/kg) fentanyl (3-5mcg/kg) propofol (3mg/kg) ```
64
What are considerations for pheochromocytoma during laryngoscopy?
must have adequate depth inhalation agent to deepen lidocaine 1-2 mg/kg IV 1 minute before opioid: 100-200mcg sufentanil 10-20mcg to attenuate sympathetic response nitroprusside 1-2 mcg/kg phentoamine: alpha blocker beta blocker: esmolol no drugs that release histamine
65
Intraoperative considerations for pheochromocytoma
``` inhalation for maintenance 1.5-2MAC more control than opioid technique combine technique with epidural opioid muscle relaxant (vec/roc) ```
66
What are blood pressure considerations for pheochromocytoma?
nitroprusside preferred phentolamine (tachyphylaxis, tachycardia, longer duration) magnesium sulfate CCB
67
How do you maintain HR with pheochromocytoma?
esmolol (preferred) labetalol metoprolol
68
When do you prepare for hypotension during pheochromocytoma?
with surgical ligation of tumor's venous drainage causes decreased catechols
69
How do you control hypotension in pheochromocytoma
stop anti-hypersensitives decrease concentration inhalation agent volume first (crystalloids/ colloids) administer pressors (phenyl, ne, dopa) combined RA/GA decrease Hypotension (adequate volume preoperatively) persistent hypotension may require an infusion of NE until the vasculature can adapt to decrease levels alpha stimulation
70
What drugs do you avoid in pheochromocytoma?
``` histamien release (morphine, atracurium) halothane succinylcholine (fasciculations of abdominal muscle wall may cause catecholamine release) pancuronium or atropine metoclopramide ```
71
What are postoperative considerations for pheochromocytoma?
``` analgesia (CLE, PCA, opioids) 50% of patients will remain hypertensive -elevated catecholamines levels for 10 days postoperatively continue antihypertensive therapy early extubation hypoglycemia steroid supplementation postoperative HTN adequate pain control ```
72
Why can you have hypoglycemia postoperative for pheochromocytoma?
excess insulin release and ineffective lipolysis and glyconeolysis

N935 Pathophysiology (6 decks)

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