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Pathophys II > Anesthesia for patients with adrenal disease > Flashcards

Anesthesia for patients with adrenal disease Flashcards

1
Q

The adrenal cortex releases

A

glucocorticoids–> cortisol
mineralocorticoids–> aldosterone
androgens

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2
Q

Describe the percentage of epinephrine and norepinephrine in the adrenal medulla

A

epinephrine 80%

norepinephrine 20%

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3
Q

The adrenal glands are

A

multifunctional and secrete a variety of hormones

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4
Q

The two portions of the adrenal gland are the

A

cortex 80-90% (zona glomerulosa, zona fasciculata, zona reticularis)
medulla 10-20%

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5
Q

There is complex regulation in the adrenal glands which is through the

A

hypothalamus–> anterior pituitary–>adrenal cortex

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6
Q

Physiological functions of the adrenal glands includes

A

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

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7
Q

Cushings syndrome is the result of

A

excessive cortisol secretion

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8
Q

Excessive cortisol secretion can be

A

ACTH dependent or

ACTH independent

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9
Q

ACTH dependent excessive cortisol secretion includes

A

Cushings disease pituitary corticotroph tumors (microadenomas)
non endocrine tumors of lung, kidney, or pancreas ectopic corticotropin syndrome

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10
Q

ACTH independent excessive cortisol secretion includes

A

benign or malignant adrenocortical tumors

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11
Q

Signs and symptoms of Cushing’s disease include

A 
sudden weight gain (usually central)
thickening of the facial fat "moon face"
electrolyte abnormalities
systemic hypertension
glucose intolerance
menstrual irregularities
decreased libido
skeletal muscle wasting
depression and insomnia
osteoporosis
hypercoagulable
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12
Q

Diagnosis of Cushing’s syndrome and disease can be performed through

A 
plasma & urine cortisol levels- 24 hour urine collection, plasma cortisol levels; if both elevated it indicates Cushing's syndrome
CRH stimulation test
dexamethasone suppression test
inferior petrosal sinus sampling
CT & MRI once diagnosis is confirmed
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13
Q

Treatment of Cushing’s syndrome is dependent

A

upon the cause
includes:
surgical-transphenoidal microadenectomy & adrenalectomy
irradiation

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14
Q

Anesthetic management considerations for patients with Cushing’s syndrome includes

A 
preop evaluation
positioning 
skeletal muscle weakness
cortisol
blood loss
choice of agents
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15
Q

Preoperative considerations for the patient with Cushing’s syndrome includes

A

HTN, intravascular volume, electrolytes- hypokalemia & hypernatremia; acid-base status- hypokalemic metabolic alkalosis; cardiac compromise- CHF; diabetes- check glucose level- control with small amounts of IV insulin

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16
Q

Positioning considerations for the patient with Cushing’s syndrome includes

A

osteoporosis & osteomalacia- vertebral compression fractures–> be careful with airway positioning
obesity
use appropriate padding
check position throughout the case
care when moving to stretcher use of roller

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17
Q

Anesthetic considerations related to muscle weakness for the patient with Cushings syndrome includes

A

hypokalemia-contributing factor
decreased requirements for muscle relaxants
use a peripheral nerve stimulator
maintain 1 twitch if using neostigmine for reversal
w/ LMA may not be able to breath adequately

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18
Q

Describe the use of cortisol for the patient with Cushing’s syndrome.

A

unilateral or bilateral adrenalectomy–> hydrocortisone usually started intraoperatively, dose reduced over 3-6 days to maintenance dose, mineralocorticoid may also need supplementation, unilateral continue therapy may not be required depending upon remaining gland

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19
Q

Blood loss for adrenalectomy for the patient with Cushing’s icnludes.

A 
may be significant
T&S
major surgery- T&C
CVP
A-line
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20
Q

Anesthetic agents for the patient with Cushings disease include

A

drugs or techniques not likely to influence attempts to decrease cortisol levels–> some inhalation agents depress adrenal response to stress & ACTh
etomidate inhibits enzymes involved in cortisol & aldosterone synthesis

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21
Q

The changes in ACTH caused by anesthetic agent or type are

A

insignificant when compared to increase in cortisol secretion with surgical stress

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22
Q

Complications of transphenoidal microadenomectomy include

A

VAE, transient diabetes insipidus, & meningitis

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23
Q

Complications with adrenalectomy are related to

A

laparoscopic–> position, insufflation

open–> pulmonary complications d/t retractors leading to atelectasis

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24
Q

Conn’s syndrome is

A

excess secretion of aldosterone from a functional tumor

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25
Q

Conn’s syndrome occurs more in

A

women than men; rarely in children

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26
Q

Conn’s syndrome results in

A

secondary hyperaldosteronism as a result of increased circulating serum renin stimulating the release of aldosterone

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27
Q

Signs & symptoms of Conn’s disease are

A

non-specific & some are asymptomatic

may also include systemic hypertension & hypokalemia

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28
Q

Systemic hypertension in Conn’s disease reflects

A

aldosterone induced sodium retention and resulting increased fluid retention. MAY BE RESISTANT TO TREATMENT
may see headache, diastolic BP 100-125 mmHg

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29
Q

Anesthesia management for the patient with hyperaldosteronism as a result of Conn’s disease includes

A

correct decreased K+ & HTN- spironolactone
assess cardiac/renal status
avoid hyperventilation–> further decreases K+
monitors: a-line
adequate fluids w/ vasodilators/diuresis
check acid-base, electrolytes frequently
exogenous cortisol 100 mg/q 24 hours

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30
Q

Addison’s disease is a result of

A

primary adrenal insufficiency due to

idiopathic/autoimmune most common primary cause

31
Q

There are no symptoms of Addison’s disease until

A

90% of adrenal cortex has been destroyed

32
Q

Addison’s disease results in deficiency of

A

all adrenal cortex secretions including mineralocorticoids, glucocorticoids, and androgens

33
Q

Signs & symptoms of Addison’s disease include

A

chronic fatigue, muscle weakness, hypotension, weight loss, anorexia, N/V, diarrhea, increased BUN & hemoconcentration due to hypovolemia; hyponatremia, hyperkalemia, hypoglycemia, abdominal or back pain, hyperpigmentation in sun-exposed areas and the distal extremities

34
Q

Diagnosis of Addison’s disease is from

A

baseline plasma cortisol level <20 ug/dL
Cortisol level <20 ug/dL after ACTH stimulation test
- cortisol levels are measured 30 & 60 minutes following administration of ACTH
-positive test yields a poor response to ACTH & is indicative of adrenal cortex impairment

35
Q

Addisonian crisis is triggered in

A

steroid-dependent individuals who do not receive increased dose during stress

36
Q

Stress for the patient with Addisonian crisis can result in

A

circulatory collapse including hypoglycemia, electrolyte imbalance, and depressed mentation

37
Q

Treatment of Addisonian crisis includes

A

IV cortisol for 24 hours
D5 0.9% NS
volume- colloid, whole blood
inotropic support

38
Q

Anesthetic management considerations for the patient with Addison’s disease include

A

administer exogenous corticosteroids
if on a daily dose- patient should take day of surgery
recommended dose for surgery is 25 mg for minor
100 mg bolus or 100 mg q6 for major

39
Q

For the patient with Addison’s disease who develops intraoperative hypotension,

A

rule out usual causes of shock

measure CVP- fluids

40
Q

Treating intraoperative hypotension for the patient with Addison’s disease includes

A

vasopressor- even if it did not have effect before cortisol
administer cortisol 100 mg IV
fluids
invasive monitoring

41
Q

Anesthetic management considerations for the Addison’s disease patient regarding electrolytes includes

A

measure glucose levels preop & every hour
hypoglycemia- replace with dextrose solutions
check electrolytes frequently- potassium levels a concerns (consider avoiding LR)

42
Q

Anesthetic management considerations for the Addison’s disease patient in regards to anesthetic medications include:

A

avoid etomidate
inhalation agents- sensitive to drug induced myocardial depression
PNS- titrate muscle relaxants due to skeletal muscle weakness

43
Q

Hypoaldosteronism is a result of

A

congenital deficiency
hyporeninemia
nonsteroidal inhibitors of prostaglandin synthesis

44
Q

Describe how hyporeninemia results in hypoaldosteronism.

A

due to long standing diabetes & renal failure and/or treatment with ace inhibitors–> loss of angiotensin stimulation

45
Q

Describe how nonsteroidal inhibitors of prostaglandin synthesis result in hypoaldosteronism.

A

May inhibit renin release and exacerbate condition in presence of renal insufficiency

46
Q

Signs and symptoms of hypoaldosteronism includes

A

hyperkalemic acidosis
severe hyperkalemia
hyponatremia
myocardial conduction defects

47
Q

Hypoaldosteronism treatment includes

A

mineralocorticoids- fludrocortisone

liberal sodium intake

48
Q

A pheochromocytoma is a

A

*** catecholamine-secreting tumor

49
Q

A pheochromocytoma originates in the

A

adrenal medulla and related tissues elsewhere in the body

  • about 90% originate in adrenal medulla with 10% involving both adrenal glands
  • most common in young to mid adult life
50
Q

Predominant symptoms of pheochromocytoma include

A

continuous or paroxysmal HTN
headache
diaphoresis/pallor
palpitations/tachycardia

51
Q

Associated symptoms of pheochromocytoma

A

orthostatic hypotension, anxiety, tremor, chest pain, epigastric pain, flushing (rare), painless hematuria (rare)

52
Q

The timing of episodes for pheochromocytoma include

A

duration: one hour or less
frequency: daily to once every few months

53
Q

Diagnosis of pheochromocytoma is through

A

urine tests- useful for screening but unreliable for definitive
plasma levels- reliability reflects the presence of pheo (more neo than epi!)
radiographic tests to locate tumor-CT/MRI

54
Q

Treatment of pheochromocytoma includes

A

surgical excision
restore intravascular volume–> decreased Hct evident
restore release of insulin with alpha block
persistant tachy-beta block (esmolol)
test: phenoxybenzamine (alpha 1 & 2) or prazosin (selective alpha 1)

55
Q

With pheochromocytoma, it is important to NOT administer

A

non selective beta block in the absence of alpha-block-heart depressed by beta block b/c unable to maintain CO w/ unopposed alpha mediated vasoconstriction

56
Q

Pertinent preop history & labs for the pheochromocytoma patient includes

A

increased PVR–> myocardial ischemia, ventricular hypertrophy, CHF, cardiomyopathy
history of cerebral hemorrhage
hyperglycemia- decreased circulating insulin with increased glycogenolysis

57
Q

Preop criteria for the patient undergoing pheochromocytoma includes

A

no BP reading >165/90 for 48 hours prior to surgery
BP on standing should not be <80/45
ECG without ET-T wave changes that are not permanent
No more than 1 PVC q 5 min.

58
Q

Fluid management for the patient with pheochromocytoma includes:

A

hypovolemic- pre-hydrate
falsely elevated HCT–> T & C
renal function
fluid replacement plan (4/2/1)

59
Q

Additional anesthetic considerations for the pheochromocytoma patient include

A

good communication with the surgeon b/c need to know when to expect hypotension
continue adrenergic blockade- depends on surgeon as may be d/c’ed prior to surgery

60
Q

Anesthetic techniques for the patient with a pheochromocytoma includes

A

heavy premedication with benzos & opioids
gentle positioning
anesthetic technique- combined GA/ continuous lumbar epidural, epidural prior to induction, invasive monitoring

61
Q

Monitors utilized for pheochromocytomas include:

A

EKG
A-line- BP control, ABGs, electrolytes, glucose levels
Swan ganz/ TEE- depends on cardiac status
CVP
U/O
temperature
peripheral nerve stimulator

62
Q

When preparing for hyperdynamic blood pressure with pheochromocytoma, consider the following medications:

A

lidocaine 1 to 2 mg/kg
propofol 3 mg/kg
opioids- do not administer morphine due to histamine release (stimulates catecholamine release)- sufentanil 0.5 to 1 mcg/kg or fentanyl 3 to 5 mcg/kg

63
Q

Laryngoscopy considerations for the patient with pheochromocytoma include

A 
must have adequate depth- inhalation agent to deepen
lidocaine IV 1-2 mg/kg 1 min. before
opioid fentanyl 100-200 mcg
nitroprusside 1-2 mcg/kg
phentolamine-alpha blockers
beta blocker- esmolol
no drugs that release histamine
64
Q

Intraoperative blood pressure control for the pheochromocytoma patient includes

A

nitroprusside–> preferred
phentolamine- tachyphylaxis, tachycardia, & longer duration
magnesium sulfate
calcium channel blockers

65
Q

Heart rate control for the patient with pheochromocytoma includes

A

esmolol-preferred
labetalol
metoprolol

66
Q

Intraoperative management of the patient with pheochromocytoma includes:

A

inhalation agent for maintenance- O2/air (desflurane- avoid d/t tachycardia, sevoflurane)
1.5-2 MAC more control than opioid technique
combined technique with epidural
opioid
muscle relaxant- vecuronium/rocuronium

67
Q

Drugs to avoid with pheochromocytoma include

A

histamine releasers- morphine, atracurium
halothane- sensitizes myocardium to epinephrine
succinylcholine- fasciculations of abdominal muscles may cause release of catechols from tumor
pancuronium & atropine
metoclopramide

68
Q

With surgical ligation of pheochromocytoma tumor’s venous drainage it results in

A

decreased catechols so prepare for hypotension by:
stopping antihypertensives
decrease concentration inhalation agent
volume first- crystal/colloids
administer pressors- phenylephrine, norepinephrine
combine RA/GA decreases hypotension- adequate volume replacement preoperatively

69
Q

Persistent hypotension with pheochromocytoma may require an

A

infusion of norepinephrine until the vasculature can adapt to decreased levels alpha stimulation

70
Q

Postoperative considerations for the patient with pheochromocytoma include

A

analgesia- CLE, PCA, opioids
50% of patients will remain hypertensive- continue antihypertensive therapy, elevated catecholamine levels for 10 days postop
early extubation- young, no lung involvement

71
Q

Describe postoperative considerations for pheochromocytoma regarding glucose control

A

hypoglycemia- excess insulin release and ineffective lipolysis and glycogenolysis

72
Q

Describe postoperative considerations for pheochromocytoma regarding steroid supplementation.

A

bilateral adrenalectomies or hypoadrenalism requires steroid supplementation

73
Q

Describe postoperative considerations for pheochromocytoma regarding postoperative HTN.

A

presence of occult tumors
volume overload
continue monitoring

Pathophys II (43 decks)

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