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Mar: Sem 6 - Adv. Principles B > Anesthesia for Endocrine Surgery > Flashcards

Anesthesia for Endocrine Surgery Flashcards

1
Q

The thyroid gland is formed by two lateral lobes connected by the _________ at about the second tracheal ring

A

Thyroid Isthmus

Thyroid Isthmus is ANTERIOR to the trachea

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2
Q

What sensory nerves innervate above the vocal cords?

A

Internal Laryngeal Branch of Superior Laryngeal Nerve

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3
Q

What sensory nerves innervate below the vocal cords?

A

Recurrent Laryngeal Nerve

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4
Q

Motor innervation to most of the intrinsic muscles of the larynx is supplied by which nerve?

This nerve does not innervate which structure of the larynx?

A
  • Recurrent Laryngeal Nerve
  • Cricothyroid Muscle
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5
Q

What nerve supplies motor innervation to the cricothyroid muscle?

A

External Laryngeal Branch of Superior Laryngeal Nerve

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6
Q

Colloid-filled follicles store what substance?

A

Thyroglobulin

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7
Q

Parafollicular cells produce what substance?

A

Calcitonin

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8
Q

What mineral fuels the production of thyroid hormones?

A

Iodine

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9
Q

What are the peripheral effects of Thyroid Hormone?

A
  • Heat generation
  • Stimulates ATP formation
  • Influences flux of ions
  • Stimulates metabolic processes ( Basal metabolic rate, protein synthesis, regulation macro metabolism)
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10
Q

What are the cardiac effects of Thyroid Hormone?

A
  • ↑ LV contractility
  • ↑ LV EF
  • Tachycardia
  • ↑ SBP and ↓ DBP
  • Chronic hyperthyroidism can lead to Heart Failure, AF, Dysrhythmias
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11
Q

Parasympathetic innervation of the thyroid comes from which nerve?

A

Vagus Nerve

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12
Q

Sympathetic innervation of the thyroid comes from which nerve?

A

Superior, Middle, and Inferior Ganglia of the Sympathetic Trunk

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13
Q

Sympathetic nerve fibers will run through the thyroid via what plexus?

A
  • Cardiac periarterial plexus
  • Superior and inferior thyroid plexus
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14
Q

What hormone regulates thyroid gland secretion?

Where does this hormone come from?

A
  • TSH
  • Anterior Pituitary Gland
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15
Q

What are the three sources of blood supply to the thyroid gland?

A
  • Superior thyroid artery (branch of ext carotid)
  • Inferior thyroid artery (branch of subclavian)
  • Thyroid ima
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16
Q

Venous drainage location of the thyroid gland.

A
  • Superior thyroid vein (IJ)
  • Middle thyroid vein (IJ)
  • Inferior thyroid vein (brachiocephalic)
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17
Q

What is the normal level of TSH?

A

0.4-5.0 milliunits/L

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18
Q

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Hyperthyroidism
T4:
T3:
TSH:

A

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Hyperthyroidism
T4: Elevated
T3: Elevated
TSH: Normal/Low

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19
Q

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Primary Hypothyroidism
T4:
T3:
TSH:

A

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Primary Hypothyroidism
T4: Decrease
T3: Decrease/Normal
TSH: Increase

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20
Q

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Secondary Hypothyroidism
T4:
T3:
TSH:

A

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Secondary Hypothyroidism
T4: Decreased
T3: Decreased
TSH: Decreased

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21
Q

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Pregnancy
T4:
T3:
TSH:

A

Give the anticipated lab values for the following thyroid disease/condition.

Dx: Pregnancy
T4: Elevated
T3: Normal
TSH: Normal

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22
Q

What type of cancer has the fastest rising incidence?

A

Thyroid cancer

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23
Q

What factors determine the prognosis of thyroid cancer?

A
  • Age of patient
  • Sex
  • Presence of metastases
  • Tumor size
  • Local invasion
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24
Q

What is the mainstay of thyroid cancer?

A

Surgical Treatment

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25
Q

Surgical options for thyroid cancer

A
  • Lobectomy
  • Total thyroidectomy
  • Total thyroidectomy plus lymph node dissection
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26
Q

What are the risks of thyroid surgery?

A
  • RLN injury (biggest risk)
  • Hypoparathyroidism (mostly temporary)
  • Bleeding

Unilateral RLN - hoarseness, global sensation, temporary
Bilateral RLN - AIRWAY issue

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27
Q

A syndrome caused by excessive secretion of TH when there is an overactive thyroid gland.

A

HYPERTHYROIDISM

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28
Q

Clinical Manifestation of Hyperthyroidism

A

Thyrotoxicosis

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29
Q

Cause of Hyperthyroidism

A
  • Graves disease (most common)
  • Thyroid adenoma
  • Thyroid carcinoma
  • TSH pituitary adenomas
  • Iatrogenic
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30
Q

Symptoms of Hyperthyroidism

A
  • Tachycardia/ Palpitations
  • Nervousness
  • Heat intolerance/ ↑ Sweating
  • Fatigue and weakness
  • ↑ Metabolism/ Weight loss
  • Hyperdefication
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31
Q

Signs of Hyperthyroidism

A
  • Thyroid enlargement
  • Tachycardia
  • Atrial fibrillation
  • Systolic hypertension ( wide pulse pressure)
  • Eye signs (exophthalmos)
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32
Q

Which gender is more prone to hyperthyroidism?

A

Female (age 20-40)

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33
Q

Possible treatments for hyperthyroidism

A
  • Anti-thyroid Drugs
  • β-blockers
  • Steroid/ Glucocorticoids
  • Radiation
  • Surgery
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34
Q

Normal T4 level

A

60-120 nmole/L

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35
Q

Factors that increase T4 level

A
  • Hyperthyroidism
  • Thyroditis
  • Early hepatitis
  • Pregnancy
  • Oestrogen therapy
  • Exogenous T4
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36
Q

Factors that decrease T4 level

A
  • Hypothyroidism
  • Androgens
  • Salicylates
  • Sulphonamides
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37
Q

Normal T3 level

A

0.92-3 nmole/L

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38
Q

Factors that increase T3 level

A

Hyperthyroidism

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39
Q

Factors that decrease T3 level

A
  • Hypothyroidism
  • Cirrhosis
  • Uremia
  • Malnutrition
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40
Q

What condition will increase TSH level?

A

Primary Hypothyroidism

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41
Q

What condition will decrease TSH level?

A

Hyperthyroidism

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42
Q

Give examples of Anti-thyroid drugs.

MOA.

A
  • PTU
  • Methimazole
  • Carbimazole
  • MOA: Inhibition of synthesis of TH by blocking the action of peroxidase, also inhibits the T4 → T3 conversion
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43
Q

MOA of how glucocorticoids treat hyperthyroidism

A
  • Decreases Release of hormone
  • Inhibits conversion T4 → T3
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44
Q

MOA of how radioactive iodine treats hyperthyroidism

A
  • Destroys follicular cells
  • Remission Rate: 80% +
  • 40% - 70% hypothyroid within ten years
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45
Q

What is the last resort for hyperthyroidism treatment?

A
  • SURGERY
  • Remission 95%
  • 10% - 30% hypothyroid w/i 20 yrs
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46
Q

Indications for Thyroid Surgery

A
  • Large goiter
  • Compressive symptoms
  • Kids
  • CA pt or suspicious nodules
  • Allergy to anti-thyroid drugs
  • Pregnant and those with a desire to conceive soon
  • Moderate to severe ophthalmopathy
  • Cosmetic desire of the patient
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47
Q

Pre-op assessment for patients undergoing thyroid surgery

A
  • Assessment of upper airway & tracheal deviation
  • Thoracic inlet X-ray, CT scan
  • Patient must be EUTHYROID
  • Use anti-thyroid drugs and β-blockers
  • Resting pulse rate 85-90 bpm
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48
Q

What drugs should you avoid during thyroid surgery?

A
  • Atropine
  • Pancuronium
  • Halothane
  • Ketamine

These drugs may activate the SNS

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49
Q

Drug of choice for induction of a hyperthyroid patient.

A
  • Etomidate
  • Propofol
  • Barbituates
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50
Q

Choice of muscle relaxant for hyperthyroidism

A
  • Atracurium
  • Vecuronium

Cardio stability

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51
Q

Choice of VA for hyperthyroid patient

A

Isoflurane

Cardio Protective

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52
Q

What type of infusion will typically be started on thyroid patients to keep HR in check?

A

Esmolol infusion 50-150 mcg/kg/min

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53
Q

What is a postoperative concern for thyroid surgery patients?

A

Thyroid storm/ crisis

An acute exacerbation of hyperthyroidism with excessive release of thyroid hormone

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54
Q

When will the patient experience a thyroid storm/ crisis?

A

Onset can be intraoperative or 6-24 hours after surgery

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55
Q

Signs and Sx of Thyroid Storm

A
  • Hyperpyrexia,
  • Tachycardia or atrial fibrillation
  • Hypotension
  • Vomiting/ Dehydration,
  • Tachypnea
  • Acute abdominal pain
  • Agitation/ psychosis

Need to R/O: MH, Pheochromocytoma, or Light Anesthesia

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56
Q

How will Thyroid Storm be managed?

A
  • PTU
  • Carbimazole
  • Sodium Iodide/ Potassium Iodide
  • Steroids
  • Receptor blockade (propanolol)
  • Tx Cardiac failure (diuretics, dig, O2)
  • Tx Hyperpyrexia
  • Tx Dehydration (IV fluids)
57
Q

What is the triad of concerns for patients undergoing thyroid surgery?

A
  • Airway obstruction
  • Tetany
  • RLN Injury
58
Q

What are the possible causes of airway obstruction in a hyperthyroid patient?

A
  • Neck hematoma w/tracheal compression
  • Tracheomalacia
  • Incomplete reversal of NDMR
  • CNS depression
59
Q

Clinical Manifestation of Tetany

A
  • Circumoral tingling
  • Paraesthesia
  • Laryngeal spasm,
  • Chvostek & Troussau signs
60
Q

Tetany can result in what type of acid-base imbalance?

A

Respiratory Alkalolsis

61
Q

Management for Tetany

A
  • Calcium Replacement
  • Slow injection of 10% calcium gluconate 10 mL IV
62
Q

Clinical Manifestation of Unilateral RLN Injury

A
  • Weak and horse voice croaking
  • Coughing when drinking
  • Aspiration
  • Usually no O2 desaturation
63
Q

Management of Unilateral RLN Iinjury

A
  • Reintubation & observe for 6-12 minutes
  • If the normal function of cords is not returned within 6- 12 minutes Teflon injection
  • Speech therapy
64
Q

Clinical Manifestation of Bilateral RLN Injury

A
  • Usually manifests immediately after extubation.
  • Laryngeal stridor
  • Acute respiratory distress
  • Phonation lost
  • O2 desaturation
65
Q

Management of Bilateral RLN Iinjury

A
  • Reintubation/ muscle paralysis
  • Hydrocortisone 100 mg TID
  • If extubation fails after 48 hrs, Tracheostomy is warranted
66
Q

What is Hypoparathyroidism?

A

Condition when the body tissues are exposed to decreased circulating concentration of thyroid hormones

67
Q

Causes of Hypoparathyroidism

A
  • Destruction of the thyroid gland
  • CNS dysfunction
68
Q

Management of Hypoparathyroidism

A
  • High dose calcium
  • Calcitriol
  • Vitamin D
  • These are often given to prevent hypocalcemia during thyroidectomy
69
Q

What lab value can be used to predict hypocalcemia?

A

Decrease PTH

70
Q

Signs and Sx of hypothyroidism

A
  • ↓ Metabolic activity
  • Cold intolerance
  • Lethargy
  • ↓ CO up to 40%
  • Prolonged circulation time
  • Narrow pulse pressure
  • ↑ PVR to decrease heat loss
71
Q

What medication is given to treat hypothyroidism?

A

Levothyroxine

72
Q

Severe form of hypothyroidism

A

Myxedema

73
Q

Clinical manifestation of Myxedema

A
  • Stupor
  • Coma
  • Hypoventilation
  • Hypotension
  • Hypothermia
  • Hypernatremia
74
Q

Myxedema is a medical emergency with a mortality rate of ________%

A

25-50%

75
Q

What induction agents will be used for Myxedema?

A
  • Ketamine is a preferable induction agent
  • If no severe CVS depression, propofol can be used
  • When using relaxants keep in mind that there is a coexisted skeletal muscle weakness, decrease the dose
76
Q

Myxedema Anesthetic Management

A
  • Hydrocortisone 100mg IV followed by 25 mg IV QID
  • Fluid and Lytes Supplementation
  • Avoid Hypothermia
  • Awake Extubation
  • Consider Ketorolac
  • Regional Anesthesia preferred over GA
77
Q

What is the NMBD of choice for Myxedema?

A

Pancuronium

Pancuronium can precipitate catecholamine release

78
Q

Factors that cause delayed emergence for myxedema patients

A
  • Hypothermia
  • Respiratory Depression
  • Slow Drug Biotransformation
79
Q

What is the best plan to establish an airway if a patient presents with a goiter?

A

Order or study imagining to determine an airway plan

80
Q

Which nerve is usually monitored during intraoperative endocrine surgery?

A

RLN

81
Q

What type of ETT is used for nerve monitoring for endocrine surgery?

A

Neural Integrity Monitor (NIM) ETT

82
Q

Goals of Intraoperative Nerve Monitoring

A
  • Prevent Nerve Injury
  • Warn when the nerve is stressed
  • Anatomical identification of nerve
83
Q

Outcomes of Nerve Monitoring

A
  • Does not prevent injury to RLN
  • Help confirm that a nerve is functionally intact prior to proceeding to the other side
  • Help the surgeon improve nerve handling
  • Can have both false-positive and false-negative signals
84
Q

Catecholamine-secreting adrenal tumors arising from chromaffin cells of the adrenal medulla

A

Pheochromocytoma

Mass on the kidney

85
Q

What is a paraganglioma?

A

Extra-adrenal pheochromocytoma

86
Q

The adrenal medulla stores what hormone?

A
  • Catecholamines
  • 80% as epinephrine
  • 20% as norepinephrine
87
Q

Catecholamines (Epi/NE) are derived from which amino acid?

A

Tyrosine

88
Q

Effects of Catecholamines

A
  • Increase glycogenolysis
  • Increase gluconeogenesis
  • Increase glucagon secretion
  • Decrease glucose uptake
89
Q

How are catecholamines cleared from the body?

A
  • Urine
  • Peripheral enzymatic degradation
  • Uptake at nerve endings
90
Q

Receptor: β1
Activity:
Symptoms:

A

Receptor: β1

Activity: Chronotrope, Inotrope, Lipolysis, Sweat Release

Symptoms: Tachycardia, Diaphoresis

91
Q

Receptor: β2
Activity:
Symptoms:

A

Receptor: β2

Activity: SM relaxation, vasodilation, glycogenolysis, gluconeogenesis, insulin secretion

Symptoms: Hypotension, Hyperglycemia

92
Q

Receptor: α1
Activity:
Symptoms:

A

Receptor: α1

Activity: SM contraction, glycogenolysis, gluconeogenesis, Na+ reabsorption, sweat release.

Symptoms: Hypertension, Hyperglycemia, Diaphoresis

93
Q

Receptor: α2
Activity:
Symptoms:

A

Receptor: α2

Activity: Inhibit the release of NE, vasoconstriction, stimulates cognition

Symptoms: Pallor

94
Q

Signs and Sx of Pheochromocytoma

A
  • HTN
  • Tachycardia
  • HA
  • Diaphoresis
  • N/V
  • Anxiety

Pretty much the feeling you get during your first day at clinical

95
Q

Dx of Pheochromocytoma

A
  • Frequently asymptomatic
  • Incidental CT Scan
  • Confirmed by biochemical testing
96
Q

What are the Biochemical studies for Pheochromocytoma?

A
  • Plasma Metanephrines
  • 24 hour catecholamines
  • Elevated serum epinephrine
97
Q

What substance will be measured in the 24-hour urine catecholamines test?

A
  • NE
  • EPI
  • Dopamine
  • Metabolites (Metanephrine, Normetanephrine, Vanillylmandelic Acid)

Board Question

98
Q

Where can Phenylethanolamine N Methylating Enzyme be found?

A
  • Adrenal Medulla
  • Organ of Zuckerkandl
99
Q

Perioperative Management Goal of Pheochromocytoma

A
  • Treat hypertension w/ α-blockade
  • Volume expansion
  • Control cardiac arrhythmia w/ β-blockade
100
Q

What two main drugs are used for α-blockade for pheochromocytoma?

A
  • Phenoxybenzamine
  • Doxazosin
101
Q

When will Phenoxybenzamine be initiated before resection of the pheochromocytoma?

A

1-3 weeks before resection

102
Q

What S/E may the pheochromocytoma patient experience once they are adequately α blocked?

A
  • Fluid Retention
  • Weight Gain
  • Orthostatic Hypotension
103
Q

When should β-blockade be initiated for pheochromocytoma patients?

A

AFTER α-blockade

If beta blockers are given first, it would block the beta receptors of the vascular smooth muscle repsonsible for vasodilation. This will cause a net effect of vasoconstriction which can worsen hypertension or pulmonary edema.

104
Q

What anesthetic drugs should be avoided in pheochromocytoma patients b/c they can precipitate catecholamine release?

A
  • Ketamine
  • Pancuronium
105
Q

Which anesthetic agents are the least cardiac depressant?

A
  • Isoflurane
  • Enflurane
  • Nitroprusside
  • Phentolamine
106
Q

During which trimester will a pheochromocytoma be resected in a pregnant patient?

A

During the 2nd trimester

107
Q

If pheochromocytoma is noted late into pregnancy, what should be the delivery method?

A
  • C-section
  • Vaginal delivery may precipitate a hypertensive crisis
108
Q

What cells make up the parathyroid gland?

A
  • Chief Cells (majority of parathyroid gland)
  • Oxyphil Cells
  • Fat Cells
109
Q

What does the Chief Cell secrete?

A

PTH

110
Q

When do Oxyphil cells begin to appear?

A

Puberty

111
Q

How many amino acids make up the PTH?

A

84 amino acids

112
Q

When will PTH be secreted?

A

PTH will be secreted from the parathyroid gland increase to low calcium levels.

113
Q

Maintenance of Ca2+, Phos, and Mag homeostasis is under the influence of which two polypeptide hormones:

A
  • Parathyroid hormone(PTH)
  • Calcitonin
114
Q

Which hormone acts directly on the bones and kidneys and indirectly on the intestine. Its production is regulated by the concentration of serum-ionized calcium.

A

PTH

115
Q

Which hormone is released by the “C” cells (Para follicular cells in the thyroid gland) in response to small increases in plasma ionic calcium. It acts on the kidneys and bones to restore the level of calcium to just below a normal set point, which, in turn, inhibits the secretion of the hormone.

A

Calcitonin

116
Q

Effects of PTH

A
  • ↑ Activity of osteoclasts causing the release of Ca from bone
  • ↑ Ca reabsorption from urine in the kidney
  • ↑ Urinary phosphate excretion
  • ↑ renal production of Vitamin D3 (calcitriol)
  • ↑ GI absorption of calcium
117
Q

What is the most common cause of hypercalcemia in outpatients?

A

Primary Hyperparathyroidism

118
Q

Which gender is more likely to have hyperparathyroidism?

A

Females are 3x more likely

119
Q

Causes of Primary Hyperparathyroidism?

A
  • 85% caused by single adenoma
  • 10% diffuse hyperplasia
  • 5% multiple adenomas
120
Q

Signs and Sx of Primary Hyperparathyroidism?

A
  • Renal
  • Skeletal
  • Abdominal
  • Cardiovascular
  • Psychiatric and neuromuscular

Stones, Bones, Groans, Moans

121
Q

Neuropsychiatric Manifestations
of Primary Hyperparathyroidism.

A
  • Easy fatiguability
  • Depression
  • Inability to concentrate
  • Memory problems
  • Proximal myopathy
122
Q

What is the only cure for Primary Hyperparathyroidism?

A

Surgery

123
Q

Effects of Bisphosphonates on Hyperparathyroidism

A
  • Bisphosphonates can lower calcium
  • May increase PTH
124
Q

Effects of Cinacalcet on Hyperparathyroidism

A
  • Cinacalcet lowers calcium
  • Modestly lowers PTH.
125
Q

Why is surgery to most optimal route for most hyperparathyroidism?

A
  • When end-organ damage occurs, it is irreversible
  • Neuropsychiatric symptoms are common and often subtle
  • The operation is very effective and has minimal morbidity
126
Q

What is involved in the surgical treatment for Hyperparathyroidism

A
  • Removal of all affected glands (one or more adenomas)
  • For diffuse hyperplasia, removal of all but approximately 50-70 mg of parathyroid tissue
127
Q

Which hyperparathyroidism surgery has a 100% success rate?

A
  • Directed parathyroidectomy
  • Requires intraoperative PTH monitoring (need an arterial line)
128
Q

What are the different ways to image the parathyroid gland?

A
  • Sestamibi scan
  • Ultrasound
  • CT (4D CT)
  • MRI

Overall sensitivity around 70-80%.
All very poor at multi-gland disease

129
Q

Preoperative Assessment for Hyperparathyroidism Surgery

A
  • Assess volume status to avoid hypotension during induction
  • Hydration w/ NS and diuresis with Lasix to decrease serum Ca levels
  • Bone fragility
  • Labs and Comorbidities
130
Q

Anesthetic Considerations for Hyperparathyroidism Surgery

A
  • Titration of muscle relaxants(pre-existing muscle weakness)
  • Avoid hypoventilation, acidosis ↑ ionized calcium → cardiac dysrhythmias.
    Tracheal manipulation during dissection
  • Proper patient positioning
  • Smooth emergence
  • Evaluate for RLN damage
  • Pain control
131
Q

Post-operative complications for Hyperparathyroidism Surgery

A
  • Neck hematoma
  • Laryngeal swelling/ glottis edema
  • RLN damage
  • Hypocalcemia= tetany
  • Acute arthritis
  • Metabolic acidosis with deterioration of renal function (transient)
  • PARATHYROID CRISIS
132
Q

What Ca2+ level is considered a Parathyroid Crisis?

A

> 15 mg/dl

133
Q

Parathyroid Crisis Management

A
  • Requires hydration (dilutes Ca++)
  • Followed by diuresis with loop diuretic (promote Ca++ & H2O excretion)
  • Glucocorticoids
  • Calcitonin
  • Dialysis
134
Q

What is the purpose of intraoperative PTH Assay?

A

To confirm that all abnormal parathyroid tissue has been removed w/o the need to physically examine all glands

135
Q

List the times you will draw a PTH during surgery.

A
  • After anesthesia induction but before neck incision (0-min or baseline)
  • During the manipulation of a suspected hyperfunctioning gland (pre-excision)
  • 5-min after gland excision
  • 10-min after gland excision
  • 20-min after gland excision
136
Q

A PTH decline of what percent indicates a successful parathyroid gland excision.

A

> 50% decline in PTH

137
Q

Outcomes after hyperparathyroidism surgery

A
  • Approx. 99% success rate
  • Increased bone density
  • Resolution of hypercalciuria.
  • Decreased risk of kidney stones
  • Improvement in neurocognitive symptoms
  • Improvement in functional ability in the elderly
138
Q

What is the gold standard surgical technique for hyperparathyroidism?

A
  • Full neck exploration
  • 99% success rate
  • Requires visualization of all four glands

Mar: Sem 6 - Adv. Principles B (14 decks)

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