Advanced | Endocrine and Anesthesia Flashcards
A 20 year old female is scheduled for adrenal mass resection. Her laboratory results are suggestive of Pheochromocytoma. Which of the following is most likely contraindicated in this patient?
A. Pancuronium
B. Esmolol
C. Clevidipine
D. Nitroprusside
A. Pancuronium
Pancuronium is a potent long-acting NMBD with vagolytic, direct
sympathomimetic stimulation because it blocks the reuptake of
norepinephrine and butyrylcholinesterase-inhibiting properties.
Which of the following post-operative plan is MOST applicable to a patient diagnosed with pheochromocytoma?
A. Monitor glucose 1-2 hours in the 1st 6 hrs post-operatively
B. About 50% of patients remain hypertensive for 1 month, hence anti-hypertensive is warranted
C. Perioperative morbidity is independent to tumor size and the degree of catecholamine secretion
D. Droperidol is an alternative drug to control PONV in patients who underwent laparoscopic removal of adrenal tumor
A. Monitor glucose 1-2 hours in the 1st 6 hrs post-operatively
TRUE or FALSE
Drugs that are known to liberate histamine release is CONTRAINDICATED in patients with pheochromocytoma
TRUE
A 30 year old male is undergoing open surgery for removal of adrenal mass. Intraoperatively, his blood pressure dramatically drops after ligation of the tumor’s venous supply. Which of the following is MOST appropriate during this time?
A. Intravascular fluid volume replacement
B. Start a phenylephrine drip immediately as soon as blood pressure drops
C. Start epinephrine drip prior to the ligation of tumor
D. Asks the surgeon to stop the dissection and infuse colloids to improve intravascular volume
A. Intravascular fluid volume replacement
A 24 year old female came in for emergency appendectomy. Upon examination, you noted a history of early onset hypertension at 16 years old. She complaints muscle weakness, polyuria, inability to concentrate urine, and episodes of hypokalemic metabolic alkalosis. Her diagnostic work-up is consistent with Conn’s Disease. Which of the following can confirm the diagnosis?
A. plasma renin activity (less than 1 ng/ml/h)
B. plasma aldosterone concentration (less than 10 ng/dL)
C. 24-hour urinary fractionated metanephrine
D. 24- hour urinary fractionated catecholamine
A. plasma renin activity (less than 1 ng/ml/h)
How do you peri-operatively prepare a pheochromocytoma patient for surgery?
READ
Which of the following is INACCURATE regarding DM type I:
A. The hyperglycemia in patients with type 1 DM can be easily controlled with oral hypoglycemic agents
B. Its propensity to develop a ketotic state is higher than DM type II
C. Type 1 DM is due to pancreatic β-cell destruction, usually leading to absolute insulin deficiency.
D. It accounts for 10% - 15% of DM cases worldwide
A. The hyperglycemia in patients with type 1 DM can be easily controlled with oral hypoglycemic agents
Which is relatively resistant to ketosis and may not be clinically apparent until exacerbated by the stress of surgery or intercurrent illness?
A. Type II DM
B. Type I DM
A. Type II DM
Patients with type 2 DM are often overweight and have resistance to the effects of insulin (commonly referred to as insulin resistance); hence, they may have normal or even elevated levels of insulin
initially.
In milder forms, type 2 DM can be treated with diet, lifestyle modifications, and oral hypoglycemic agents. Because these patients are relatively resistant to ketosis, their disease may not be clinically apparent until exacerbated by the stress of surgery or intercurrent illness
Clinical DM can be a result of a disease that damages the pancreas and thus impairs insulin secretion. The following disease states can commonly lead to secondary diabetes EXCEPT:
A. Tacrolimus therapy (after transplant)
B. Cystic fibrosis
C. Pheochromocytoma
D. Addison’s Disease
E. Acromegaly
Addison’s Disease
Other types of DM can be a result of a disease that damages the pancreas
and thus impairs insulin secretion. Pancreatic surgery, chronic pancreatitis,
cystic fibrosis, and hemochromatosis can damage the pancreas and impair
insulin secretion sufficiently to produce clinical DM.
DM can also result from one of the endocrine diseases that produces a hormone that opposes the action of insulin. Hence, a patient with a glucagonoma, pheochromocytoma, or acromegaly may develop diabetes. An increased effect of glucocorticoids, from either Cushing disease or steroid or tacrolimus therapy (after organ transplantation), may also oppose the effect of insulin enough to elicit
clinical diabetes and would certainly complicate the management of preexisting
diabetes.
Which of the following statements about pheochromocytoma is INACCURATE?
A. Preoperative administration of alpha-adrenergic inhibitors will usually reverse EKG changes due to catecholamine myocarditis
B. Preoperative administration of alpha-adrenergic inhibitors decreases operative mortality
C. Beta-adrenergic inhibitors should be administered preoperatively only in conjunction with alpha-adrenergic inhibitors
D. Vasopressor therapy may be necessary postoperatively for treatment of hypotension
E. Fluid limitation to reverse the catecholamine-induced volume overload
during alpha blockade
E. Fluid limitation to reverse the catecholamine-induced volume overload
during alpha blockade - FALSE STATEMENT
- Although preoperative intravenous volume repletion does not optimize hemodynamics or improve outcomes, the Endocrine Society Task Force guidelines further recommend a high sodium diet (3–5 g/day) and fluid intake to reverse the catecholamine-induced volume contraction
during alpha blockade. - Beta blockers are started only after adequate alpha blockade to prevent worsening hypertension due to
the blockade of vasodilatory peripheral β-adrenergic receptors and unopposed alpha stimulation.
Miller | 10th edit
A 50 year old female ASA III for uncontrolled type II DM is scheduled for an elective laparoscopic cholecystectomy. Upon pre-operative evaluation, She ask you which of the following oral hypoglycemics can MOST likely induce ketoacidosis?
A. (SGLT2) inhibitors
B. Dipeptidyl-peptidase-4 inhibitors
C. Sulfonylureas
D. α-Glucosidase inhibitors
A. (SGLT2) inhibitors
Sodium-glucose cotransporter 2 (SGLT2)
inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) provide
insulin-dependent glucose lowering by blocking glucose reabsorption in the
proximal renal tubule via SGLT2 inhibition.
There is an increased risk of ketoacidosis in patients with type 1 and type 2 DM who are treated with SGLT2 inhibitors.
- Dipeptidyl-peptidase-4 inhibitors (e.g. sitagliptin) slow degradation of incretin
hormones, increase endogenous incretin hormone levels, and improve postprandial hyperglycemia. - Sulfonylureas (e.g. gliclazide and glimepiride) enhance β-cell insulin secretion
- alpha glucosidase inhibitors decrease postprandial glucose absorption
Determining the glucose-lowering regimen in DM patients play a crucial role in the pre-operative management. Which of the following is the MOST ACCURATE pre-operative management?
A. Patients who are on sulfonylureas are
particularly have the lowest risk in developing hypoglycemia
B. Metformin should be withheld on the day of surgery
C. SGLT2 inhibitors must be discontinued 12 hours before the surgery
D. generally, oral antihyperglycemic medications are advised to be continued the night before surgery.
B. Metformin should be withheld on the day of surgery
A. Patients who are on sulfonylureas are
particularly have LEAST risk for developing hypoglycemia - FALSE.
* Sulfonylureas have particularly higher propensity to develop hypoglycemia.
C. SGLT2 inhibitors must be discontinued 12 hours before the surgery - FALSE
- It should be withheld 3 - 4 days before surgery.
D. generally, oral antihyperglycemic medications are advised to be continued the night before surgery. FALSE
- generally, oral antihyperglycemic medications are advised to be DIScontinued the night before surgery
Barash | 9th edit
The following PRE-OPERATIVE management is TRUE among DM patients who are on insulin therapy EXCEPT?
A. If patients are using a premixed insulin, they are instructed to reduce their evening dose by 20% and hold insulin completely on the morning of the procedure
B. Patients with type 2 DM need some basal insulin at all times
C. Patients on insulin pump therapy should have their blood glucose checked every hour intraoperatively
D. Intermediate- or long-acting insulin dose
should be reduced by 20% the night before surgery.
B. Patients with type 2 DM need some basal insulin at all times
As per guideline, a patient with type II DM is allowed to undergo elective surgery if the HBA1c is:
A. < 6.5%
B. < 8%
C. 10% or less
D. 5.5 - 6.5% only
B. < 8%
- Despite the lack of high-quality evidence, an HbA1c level <8% is now being recommended for adult patients with diabetes undergoing elective surgical procedures.
Similarly, the European Society of Cardiology recommends that elective noncardiac surgery be postponed in patients with an HbA1c ≥8.5%, if it is “safe and practical.
Barash | 9th edit page 4045
Which of the following peri-operative management is ACCURATE among patients with long standing DM?
A. Blood glucose should be monitored every 4 to 6 hours while the patient is on NPO status
B. Hyperglycemia in a hospital setting is defined as any blood glucose higher than 110 mg/dL
C. Glycemic lability index may be the least
discriminator for mortality among expression of glucose variability parameters
D. ADA recommends a target range 80 to 180 mg/dL for blood glucose in the perioperative period
E. The recommended threshold to initiate an insulin infusion is no higher than
140 mg/dL.
A. Blood glucose should be monitored every 4 to 6 hours while the patient is on NPO status
All the other statements are FALSE.
TRUE or FALSE
In NON-critically ill hospitalized patients, the goal is to keep the glucose level between 120 and 180 mg/dL
FALSE
80 -180 mg/dL is the GOAL in NON-critically ill patients.
Barash | 9th edit
Preoperative administration of an alpha-adrenergic blocker for 10 days to patients with pheochromocytoma will decrease
A. episodic tachycardia
B. hyperglycemia
C. hypovolemia
D. nasal stuffiness
E. postural hypotension
C. hypovolemia
Current guidelines endorse an optimal
duration of alpha blockade between 7 and 14 days preoperatively.
Preoperative duration of alpha blockade for more than 30 days is associated with intraoperative bradycardia and postoperative hypotension requiring vasopressor support.
miller | 10th edit
An elderly patient came to the ER for what seems to be an acute abdomen probably secondary to ruptured viscus. She is a known diabetic with an RBS of 650 mg/dL. If this patient is having hyperglycemia crisis, which of the following is the MOST appropriate management?
A. Correction of non-anion gap metabolic acidosis
B. A continuous infusion is started at 0.1 unit/kg/h as long as serum potassium is above 3.3 mEq/L
C. If the blood glucose does not fall by 10% in the first hour, a bolus of 1.0 unit/kg is
administered
D. Ringer’s lactate is an absolute contraindication in hyperglycemic crisis
B. A continuous infusion is started at 0.1 unit/kg/h as long as serum potassium is above 3.3 mEq/L
Which of the following oral antidiabetic drugs is unique in that it does NOT
produce hypoglycemia when administered to a fasting patient?
A. Glyburide (Micronase)
B. Glipizide (Glucotrol)
C. Tolbutamide (Orinase)
D. Metformin (Glucophage)
D. Metformin (Glucophage)
Oral agents that are used to help control hyperglycemia in type 2 diabetic patients (relative β-cell insufficiency and insulin resistance) include four major drug classes:
1. drugs that stimulate insulin secretion (hypoglycemia is a risk)
a. sulfonylureas
i. first-generation (chlorpropamide,
tolazamide, tolbutamide)
ii. second-generation (glimepiride,
glipizide, glyburide)
b. meglitinides (repaglinide, nateglinide)
- Drugs that decrease hepatic gluconeogenesis (hypoglycemia not a
risk)
- biguanides (metformin)
- Drugs that improve insulin sensitivity (hypoglycemia not a risk)
a. thiazolidinediones (rosiglitazone, pioglitazone)
b. glitazones
- Drugs that delay carbohydrate absorption (hypoglycemia not a
risk)
a. α-glucosidase inhibitors (acarbose, miglitol)
Only drugs that stimulate insulin secretion are a risk for producing hypoglycemia.
Initial therapy is usually with second-generation sulfonylureas (more potent
and fewer side effects than first-generation sulfonylureas) or with a biguanide
Which of the following is the most common cause of hyperthyroidism?
A. Multinodular diffuse goiter
B. Thyroid adenoma
C. Papillary Adenocarcinoma
D. Hashimoto thyroiditis
Multinodular diffuse goiter or Graves disease
This condition predominantly affects women between the ages of 20 and 40.
What is the second most common cause of hyperthyroidism?
A. Multinodular diffuse goiter
B. Thyroid adenoma
C. Papillary Adenocarcinoma
D. Hashimoto thyroiditis
Thyroid adenoma
Thyroid adenomas can lead to increased thyroid hormone synthesis.
What role does amiodarone play in hyperthyroidism?
It is an antiarrhythmic agent that is iodine-rich and can cause iodine-induced thyrotoxicosis
This can lead to increased thyroid hormone levels.
A 34 year old female is diagnosed with hyperthyroidism and is scheduled for an emergency surgery. In order to control a clinically acceptable heart rate prior to surgery, beta-blockers is started. beta-blockade is administered to achieve which of the following?
A. beta-blockade is primarily used to prevent storm
B. beta-blockade is used to achieve a HR below 110
C. beta-blockade is used to achieve a HR below 90
D. beta-blockade reduces T3 secretion
C. beta-blockade is used to achieve a HR below 90
If a hyperthyroid patient with
clinically apparent disease requires emergency surgery, β-adrenergic
blockade should be administered to achieve a heart rate below 90 beats per
minute.
- β-Blockers do not prevent thyroid storm.
Glucocorticoids such as dexamethasone (8 to 12 mg/d) are used in the management of severe thyrotoxicosis because they reduce thyroid hormone secretion and the
peripheral conversion of T4 to T3.
Which of the following peri-operative management is LEAST LIKELY applicable to a patient with Hyperthyroidism:
A. All antithyroid medications are continued through the morning of surgery
B. In a clinically euthyroid patient, Ketamine may be used
C. generally, the initial dose of muscle relaxant is reduced
D. Anti-thyroid medications are withheld 24 hours prior to surgery
D. Anti-thyroid medications are withheld 24 hours prior to surgery
Barash | 9th edit
Dr. Rataban is doing her pre-operative rounds on a patient. Her patient is a known hyperthyroid and is scheduled for a lobectomy. Which of the following hyperthyroid-associated conditions would make her cautious in the dosing of muscle relaxants intraoperatively?
A. Multiple sclerosis
B. Myasthenia gravis
C. ALS
D. Neuroleptic Malignant Syndrome
B. Myasthenia gravis
The incidence of myasthenia gravis is increased in hyperthyroid patients; thus, the initial dose of muscle relaxant should be reduced, and a twitch monitor should be used to titrate subsequent doses.
A 35 year old ASA III female underwent bilateral adrenalectomy. The surgery was uneventful. At the PACU, you plan to maintain her on fludrocortisone. What is the maintenance dose of fludrocortisone (9-α-fluorohydrocortisone) in this particular case?
A. 0.05 to 0.1 mg/d
B. 0.5 to 1 mg/d
C. 1 to 5 mg/d
D. 10 to 15 mg/d
A. 0.05 to 0.1 mg/d
After bilateral adrenalectomy, most patients require 0.05 to 0.1 mg/d of fludrocortisone (9-α-fluorohydrocortisone) starting around day 5 to provide mineralocorticoid activity.
Slightly higher doses may be needed if
prednisone is used for glucocorticoid maintenance because it has little intrinsic mineralocorticoid activity.
Following a total thyroidectomy, a 38-year-old woman develops hyperthermia and tachycardia in the recovery room. After several other differential diagnoses are ruled out, thyroid storm is suspected. Which of the following treatment options is initiated first?
A. Volume, electrolyte, and glucose replacement
B. Cooling blankets, ice packs, and aspirin to decrease the temperature
C. Iodide to inhibit thyroid hormone synthesis
D. Bisoprolol to inhibit the peripheral conversion of T 3 to T 4
E. Surgical decompression
A. Volume, electrolyte, and glucose replacement
A reduction of temperature can be achieved with acetaminophen, cold lavage of body cavities, cooling blankets, ice packs, and reduction of ambient temperature.
Aspirin should not be used as an antipyretic. It displaces thyroid hormones from binding proteins, thereby raising free hormone levels.
Inotropes, diuretics, and supplemental oxygen may be needed
for acute congestive heart failure.
Magnesium can be used to
reduce the severity and incidence of cardiac arrhythmias. Iodide can be used to inhibit thyroid hormone synthesis.
However, iodide therapy should be delayed aft er beginning antithyroid drug therapy. Antithyroid drugs reduce the secretion and production of thyroid hormones and prevent
iodide binding in the thyroid within the hour.
Catecholamines contribute to the symptoms of thyrotoxicosis.
Beta blockers are effective in attenuating the manifestations of excessive sympathetic activity. Beta blockers alone do not inhibit hormone synthesis, but specifically propranolol does impair the peripheral conversion of T 4 to T 3 over 1 to 2 weeks.
Any beta blocker may be used,
but preoperatively propranolol (in doses titrated to effect) plus potassium iodide (two to five drops every 8 hours) is frequently used before surgery to decrease cardiovascular symptoms and reduce circulating concentrations of thyroid
hormones.
Preoperative preparation usually requires 7 to 14 days. Rate control may improve congestive heart failure due to poorly controlled paroxysmal atrial fibrillation. Impaired left ventricular function secondary to hyperthyroidism may not be corrected with the use of beta blockers.
If a hyperthyroid patient with clinically apparent disease requires emergency surgery, beta blockers should be titrated to achieve a
heart rate of less than 90 beats per minute.
Beta blockers do not prevent thyroid storm. If beta blockers are contraindicated, other sympatholytic drugs may be useful (reserpine
[depletes catecholamine stores] or guanethidine [inhibits catecholamine release]).
There are no signs of hematoma formation. Therefore, surgical decompression is not the correct choice.
A 46-year-old woman with a history of Graves disease is brought to the ED several hours after outpatient plastic facial surgery.
She is delirious and agitated with the following vital signs:
Temperature - 39.2°C
BP - 140/60 mm Hg
RR - 35/min
Focused physical examination is otherwise unremarkable. Medications include propylthiouracil and a diuretic. A WBC is 10,000 with no left shift. Findings from other examinations, including CXR and urinalysis, are negative. Treatment at this time should include:
A. Aspirin to treat hyperpyrexia
B. Calcium gluconate infusion to prevent rebound hypocalcemia
C. Propranolol 1–2 mg slow IV push
D. Ice baths
E. Gentamicin 100 mg and ampicillin 1 g IV
C. Propranolol 1–2 mg slow IV push
Thyroid storm may be precipitated in stressed hyperthyroid patients. Recent surgery and infection are two common causes. A major side effect of antithyroid drugs is leukopenia, but the white count is normal in this case.
Mental status changes, hyperpyrexia, tachycardia, and diarrhea are the most typical manifestations; however, patients may present with lethargy, coma, and muscle weakness without the usual hyperdynamic symptoms (apathetic thyrotoxicosis) or unremitting atrial fibrillation and CHF. Thyroid storm is a clinical diagnosis. IV fluids for dehydration and supplemental oxygen should be given.
Dexamethasone blocks peripheral conversion of T4 to T3.
Propylthiouracil blocks the synthesis of thyroid hormone. Iodine is given 1 hour after antithyroid medication to inhibit thyroid hormone release.
Propranolol blocks the sympathetic manifestations and blocks the peripheral conversion of T4 to T3. The mortality of untreated thyroid storm is virtually 100%.
Aspirin should be avoided, as it can displace thyroid hormone from its binding sites and worsen the thyroid storm.
The following are common complications of thyroidectomy EXCEPT?
A. Recurrent laryngeal nerve (RLN) damage
B. Tracheal compression
C. Hypoparathyroidism
D. Pneumothorax
E. Phrenic nerve injury
E. Phrenic nerve injury
The following are some of the most common complications of thyroidectomy
- Recurrent laryngeal nerve (RLN) damage, tracheal compression, hypoparathyroidism, pneumothorax
Tracheal compression may occur secondary to hematoma or tracheomalacia, and pneumothorax can occur during resection of substernal goiters.
When do symptoms of hypocalcemia typically develop after surgery?
A. 5 - 7 days
B. 1 - 2 weeks
C. 24 - 72 hrs
D. less than 6 hrs
Within 24 to 72 hrs
Symptoms can include laryngeal stridor and laryngospasm.
What treatment is warranted in case of hypocalcemic tetany?
A. Sodium Iodide
B. Calcium gluconate
C. PTU
D. Dexamethasone
Intravenous (IV) administration of calcium chloride or calcium gluconate
Magnesium levels should also be monitored and corrected if low.
TRUE or FALSE
Unilateral RLN injury MORE common than bilateral injury
True
Unilateral is more often encountered in the setting of thyroidectomy. This usually present as hoarseness as opposed to ‘stridor’ or ‘aphonia’ which is a manifestation of bilateral injury to the RLN.
Unilateral injury is often transient.
Which of the following glucocorticoid has the highest anti-inflammatory property?
A. Prednisone
B. Dexamethasone
C. Hydrocortisone
D. Triamcinolone
B. Dexamethasone
Which of the following glucocorticoid has the lowest anti-inflammatory property?
A. Cortisone
B. Prednisolone
C. Hydrocortisone
D. Prednisone
A. Cortisone
A 40 year old female came in for an emergency appendectomy however she seems to have some clinical signs and symptoms consistent with hypocalcemia due to a chronic hypoparathyroid state. The clinical signs of hypocalcemia would include EXCEPT?
A. Depression
B. Muscle stiffness
C. Paresthesias
D. Short QT intervals
E. Trousseau sign
D. Short QT intervals - FALSE
Hypocalcemia = Prolonged qT interval
The clinical signs of hypocalcemia include clumsiness, convulsions, laryngeal stridor, depression, muscle stiffness, paresthesias, parkinsonism, tetany, Chvostek sign, dry and scaly skin, brittle nails, coarse hair, low serum concentrations of calcium, prolonged QT intervals, soft tissue calcifications, and Trousseau sign.
Hypocalcemia* DELAYS VENTRICULAR REPOLARIZATION*, hence increasing the QTc interval. Heart failure may occur with hypocalcemia but is rare. Patients with hypocalcemia may have seizures, often indistinguishable from epilepsy in the
absence of hypocalcemia.
Which of the following laboratory findings is most consistent in a patient with adrenal insufficiency?
A. High sodium, high potassium, high glucose
B. High sodium, low potassium, low glucose
C. Low sodium, high potassium, low glucose
D. Low sodium, low potassium, high glucose
E. Low sodium, low potassium, low glucose
C. Low sodium, high potassium, low glucose
The usual laboratory findings in patients with primary adrenal insufficiency include hyponatremia, hyperkalemia, hypoglycemia, and azotemia.
Hyponatremia is present in 88% of cases and is usually mild to moderate; severe hyponatremia (<120 mEq/L) is rare.
Hyperkalemia is present in 64% of cases, usually mild; the potassium level rarely exceeds 7 mEq/L. Two-thirds of patients with adrenal failure have hypoglycemia and the glucose levels less than 45 mg/dL; the pathophysiology is decreased gluconeogenesis and increased peripheral glucose use secondary to lipolysis.
A 54 year female underwent thyroidectomy under GA-GETA. Post-operatively, the patient awakened, and intact RLN was clinically demonstrated. Extubation was uneventful. 2 days later, the patient has severe stridor and upper airway obstruction. The MOST likely cause is?
A. Damage to RLN
B. SLN
C. Tracheomalacia
D. Hypocalcemia
E. Hematoma
D. Hypocalcemia
The Key is TIMING: 2 days.:)
Hoarseness and severe stridor presenting 24-96h after total thyroidectomy would most likely be consistent with decreased calcium
Barash | 9th edit
A known hypothyroid patient came in for emergency pelvic laparotomy. At the pre-operative area, she is hypo-ventilating, and hypothermic. Her blood pressure is 80/50. To rule out co-existing metabolic problem, you plan to check for her electrolyte panel. Which of the following is MOST likely consistent with a severe form of hypothyroidism?
A. Hyponatremia
B. Hypernatremia
C. Decreased PcO2
D. Respiratory alkalosis
A. Hyponatremia
Myxedema coma represents a severe form of hypothyroidism
characterized by stupor or coma, hypoventilation, hypothermia, hypotension, and hyponatremia. This is a medical emergency with a high mortality rate (25% to 50%) and, as such, requires aggressive therapy
Which of the following peri-operative management of severe hypothyroidism (myxdema coma) is INACCURATE?
A. Only lifesaving surgery should proceed in the face of myxedema coma.
B. IV thyroid replacement is initiated as soon as the clinical diagnosis
C. Loading dose of IV T3 is also used but it has slower onset compared to IV T4
D. Steroid is an essential component of the anesthetic plan
C. Loading dose of IV T3 is also used but it has slower onset compared to IV T4 - INACCURATE statement.
IV thyroid replacement is initiated as soon as the clinical diagnosis is made. An IV loading dose of T4 (sodium levothyroxine, 200 to 300 mcg) is given initially and followed by a maintenance dose of T4, 50 to 200 mcg/d intravenously.
Alternatively, T3 may be used because it has a more RAPID ONSET.
IV T3 has a more rapid onset than IV T4(sodium levothyroxine).
- Loading dose of Thyroid replacement therapy (sodium levothyroxine) is 200 to 300 mcg)
Which of the following peri-operative management of Hyperparathyroidism is MOST likely INACCURATE?
A. A serum Ca2+ concentration exceeds 15 mg/dL (7.5 mEq/L) should be corrected prior to surgery
B. Ideally, there is an increased requirement for NMB agent on induction
C. Rehydration alone is capable of lowering the serum Ca2+ level by at least 2 mg/dL.
D. Hyperkalemia and
hypermagnesemia is expected after correction of calcium elevation
E. Glucocorticoids has little role in correction of primary hypercalcemia
D. Hyperkalemia and hypermagnesemia is expected after correction of calcium elevation - INACCURATE statement
Hypokalemia and hypomagnesemia is seen in patients who have underwent emergency correction of hypercalcemia.
Glucocorticoids are usually of no benefit in the treatment of primary hypercalcemia. Finally, hemodialysis or peritoneal
dialysis can be used to lower the serum Ca2+ level when alternative regimen are ineffective or contraindicated.
There is no evidence that a specific anesthetic drug or technique has
advantages over another. A thorough knowledge of the clinical manifestations attributable to hypercalcemia is of the greatest value in choosing an anesthetic technique.
Special monitoring is usually not required. There is an increased requirement for vecuronium, and probably all nondepolarizing
muscle relaxants during onset of neuromuscular blockade
Which of the following should be AVOIDED in the peri-operative management of a patient with Hypercalcemia secondary to parathyroid adenoma?
A. Calcitonin
B. Thiazide
C. Bisphosphonates
D. Saline infusion
E. Mithramycin
B. Thiazide
Although diuresis play an important role in the management of hypercalcemia, Thiazides should be strongly avoided because it may ENHANCE renal tubular reabsorption of Ca.
On the other hand, furosemide, a loop diuretic is commonly used as the diuretic drug of choice. Furosemide INHIBITS Na and Ca reabsorption
Which of the following is NOT consistent with CUSHING syndrome?
A. Hyperglycemia
B. Hypertension
C. Increased intravascular fluid
D. Hyperkalemia
E. Osteoporosis
D. Hyperkalemia
Cushing syndrome, caused by either overproduction of cortisol by the adrenal cortex or exogenous glucocorticoid therapy, is a syndrome characterized by truncal obesity, hypertension, hyperglycemia, increased
intravascular fluid volume, hypokalemia, fatigability, abdominal striae, osteoporosis, and muscle weakness
Which of the following is MOST likely inaccurate regarding steroid replacement during the perioperative period?
A. The pituitary–adrenal axis is usually considered to be intact if a plasma cortisol level higher than 19 mcg/dL is measured during acute stress
B. The degree of adrenal responsiveness has been correlated with the duration of surgery
C. Regional anesthesia during
surgery of the lower abdomen and extremities is not effective in postponing the elevation in cortisol levels.
D. Deep general anesthesia may also suppress the elevation of stress hormones such as ACTH
C. Regional anesthesia during
surgery of the lower abdomen and extremities is not effective in postponing the elevation in cortisol levels. - INACCURATE statement.
Regional anesthesia is effective in postponing the elevation of cortisol.
All the other statements are accurate.
Barash | 9th edit
TRUE or FALSE
Daily morning doses of prednisone less than 5 mg are not associated with HPA suppression.
TRUE
A 70 year old female is scheduled for joint replacement surgery. She have had significant history of steroid use for the past 4 weeks. Which of the following anesthetic preparation is most likely applicable to her chronic steroid intake?
A. She should take her usual morning steroid dose plus 50 mg hydrocortisone IV prior to induction and 25 mg q8h for 24–36 hrs
B. Administer 50 mg hydrocortisone IV prior to induction and 25 mg q8h for 24–36 hrs
C. Take usual morning steroid dose. Administer 50 mg IV hydrocortisone IV prior to induction and 100 mg IV q8h for 24–36 hrs
D. No supplement steroid is needed since the surgery is associated with a mild risk of stress
B. Administer 50 mg hydrocortisone IV prior to induction and 25 mg q8h for 24–36 hrs
For surgeries associated with moderate stress, such as joint replacement, a common regimen involves patients taking their usual morning steroid dose, then supplementing with hydrocortisone 50 mg IV at induction, followed by
hydrocortisone 25 mg IV every 8 hours for six doses, along with resumption of usual home regimen on the second postoperative day.
For major surgeries
(e.g., coronary artery bypass graft), patients are instructed to take their usual morning steroid dose, then supplemented with hydrocortisone 100 mg IV at induction, followed by hydrocortisone 50 mg every 8 hours for at least six doses.
In a patient with pheochromocytoma, Which of the following is the clinician’s recommended duration of alpha-blockade therapy before the proposed surgery?
A. 10 - 14 days
B. 5 - 7 days
C. 3 - 4 weeks
D. 24 - 48 hrs
A. 10 - 14 days
Although the optimal period of preoperative treatment has not been established, most clinicians recommend beginning α-blockade therapy at least 10 to 14 days
before the proposed surgery; however, periods as short as 3 to 5 days have been used.
TRUE or FALSE
A patient undergoing treatment for Pheochromocytoma should be given beta-blockade prior to adequate alpha-blockade.
FALSE
β-Blockers should NOT be given
until adequate α-blockade is ensured to avoid the possibility of unopposed α-
mediated vasoconstriction.
This medication is generally reserved for patients with metastatic disease or for
situations in which surgery is contraindicated and long-term medical therapy is required:
A. α-Methyltyrosine
B. Phentolamine
C. Doxazosin
D. Glucocorticoids I
A. α-Methyltyrosine
- It is an inhibitor of catecholamine biosynthesis
A 20 year old male came in at the ER for emergency abdominal surgery. She have had history of elevated BP and tachycardia without medications. Her history and lab work-ups are consistent with Pheochromocytoma however she was not started with treatment prior to the emergency surgery. Which of the following agent is most priority in controlling her sympathetic-mediated symptoms?
A. IV Nitroprusside
B. α-Methyltyrosine
C. IV Doxazosin
D. IV Propranolol
A. IV Nitroprusside
75 year old male is found unresponsive is diagnosed with hyperosmolar, hyperglycemic state (HHS) with serum glucose of 1450 mg/ dL and CT evidence of appendicitis. The surgeon books an exploratory laparotomy as an emergency because the patient’s BP is 65/35 and HR 125.
Which of the following is the most appropriate course of action:
A. Administer an isotonic crystalloid to decrease the glucose by 50 mg per hour, proceed with surgery when the glucose is < 500
B. Administer a hypotonic crystalloid to decrease the glucose by 50 mg per hour, proceed with surgery when the glucose is < 500
C. Administer isotonic crystalloid until the MAP is 60, and proceed to surgery regardless of serum glucose
D. Administer hypotonic crystalloid until the MAP is 60, and proceed to surgery regardless of serum glucose
C. Administer isotonic crystalloid until the MAP is 60, and proceed to surgery regardless of serum glucose
