Endocrine Flashcards

1
Q

islets of langerhans

A
  • make up 1-2% of pancreas weight
  • hormones are produced and do not enter ducts but are secreted into the capillary blood vessel
  • venous blood from islet drains into the hepatic portal vein and then into general circulation
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2
Q

four cells in the islets of langerhans

A
  • delta
  • pancreatic polypeptide (PP)
  • alpha
  • beta
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3
Q

beta cells

A
  • compromise 60-70% of islet mass

- secrete insulin

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4
Q

alpha cells

A
  • compromise 25% islet mass

- secrete glucagon

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5
Q

delta cells

A

secrete somatostatin

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6
Q

three major hormone classifications

A
  • peptides/proteins –> insulin and glucagon
  • amino acid –> dopa and epi
  • steroids –> lipid soluble, derived from cholesterol (like estrogen or progesterone)
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7
Q

insulin

A
  • synthesized in beta cells
  • released via exocytosis to the capillary then enters portal circulation
  • half life = 5-8 min
  • major hormone degradation sites are liver and kidney
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8
Q

insulin function

A
  • key hormone controlling glucose removal from the plasma
  • facilitates transport of glucose by stimulating uptake into the liver, muscle, and adipose tissue
  • brain = one of the few tissues that does not require insulin or glucose for transport into cells
  • liver = insulin promotes efficient storage of excess glucose in the form of glycogen (glycogenesis)
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9
Q

pancreatitis

A
  • inflammation of the pancreas which is commonly caused by gallstones and alcohol
  • can also be caused by trauma such as ERCP, obstruction and certain medications
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10
Q

pancreatitis clinical presentation

A
  • abdominal pain
  • N/V
  • febrile
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11
Q

pancreatitis anesthetic considerations

A
  • early hydration
  • pain meds
  • electrolytes
  • patient NPO until pain and inflammation has resolved
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12
Q

pancreatitis labs

A
  • elevated WBC count
  • possible ARF
  • liver dysfunction
  • electrolyte abnormalities
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13
Q

pancreatitis complications

A
  • pancreatic necrosis = cell death secondary to inflammation

- pancreatic pseudocyst = contains only fluid and is the most common complication of chronic pancreatitis

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14
Q

pancreatic cancer

A
  • fourth most common cause of cancer deaths in the US

- risk factors = obesity, smoking, chronic pancreatitis

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15
Q

pancreatic cancer s/s

A
  • abdominal pain
  • weight loss
  • pain = retroperitoneal invasion
  • jaundice = biliary obstruction
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16
Q

pancreatic cancer treatment

A
  • surgical resection is the only effective treatment
  • patient with tumor in head of pancreas develop painless jaundice and are usually candidates for surgical resection
  • most common techniques = pancreatectomy or whipple
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17
Q

Cystic fibrosis

A
  • autosomal recessive
  • mutation of chromosome 7
  • defective chloride ion transport in epithelial cells in lungs, pancreas, liver, GI and reproductive organs
  • decreased chloride –> decreased transport of sodium and water –> viscous secretions that are luminal obstruction and scarring to exocrine glands
  • primary M&M = chronic pulmonary infection
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18
Q

CF anesthetic implications

A
  • elective surgery delayed until optimal pulmonary function obtained
  • volatiles decrease airway pressure by decreasing bronchial smooth muscle and decreasing hyperactive airways
  • AVOID anticholinergics to maintain secretions in less viscous state
  • intubated –> need to suction
  • DEEP - to minimize coughing
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19
Q

T1DM

A
  • T cell mediated destruction of beta cells in pancreas

- 80-90% of beta cell function lost before hyperglycemia occurs

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20
Q

T1DM patient presentation

A
  • hyperglycemia
  • fatigue
  • weight loss
  • polyuria
  • blurred vision
  • intravascular volume depletion
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21
Q

T1DM diagnosis

A

BG >200

HgA1C > 7

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22
Q

what form of DM is DKA most associated with?

A

T1DM

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23
Q

T2DM

A
  • insulin resistance and beta cell insufficiency
  • insulin resistance leads to circulating free fatty acids, cytokines, insulin antagonist and target tissue defects at insulin receptors
  • impaired glucose associated with increase in body weight, decrease in insulin secretion sand reduction in peripheral insulin action
  • increased insulin levels = densitization of target tissue, causing decreased response to insulin
24
Q

Symptoms of T2DM

A
  • polyuria
  • polydipsia
  • weight loss
  • fasting glucose >126
  • 2 hour plasma glucose level >200 during oral glucose test
25
what are factors that can lead to insulin resistance?
- abd obesity - excess calorie consumption - lack of exercise - genetic susceptibility
26
what are reasons preop hyperglycemia is undesirable?
- dehydration occurs due to osmotic diuretic effect of glucose - accumulation of lactate - impaired immune response which increases incidence of post-op infections - exacerbation of brain, CV, and renal ischemic changes
27
systemic effects of hyperglycemia
- risk of heart disease - fatigue and lack of energy - pancreas malfunction - risk of infection - high blood pressure - gastroparesis - risk of cataracts and glaucoma
28
three life threatening complications of DM
- DKA - HHS - hypoglycemia
29
DKA
- most common cause is infection | - decreased insulin leads to catabolism of free fatty acids into ketones which results in DKA
30
DKA treatment
- correction of hypovolemia, hyperglycemia, and total body potassium deficit - close anion gap!! - when glucose moves into the cell, so does potassium so you MUST monitor labs frequently
31
hypoglycemia
- brain depends on glucose as source of energy, which makes it very susceptible to hypoglycemia - if not treated, mental status change, anxiety, lightheaded and coma may occur
32
systemic manifestations of hypoglycemia
- diaphoresis - tachycardia - nervousness
33
metabolic syndrome
- have clinical characteristics that are frequently seen in patients that are at risk for T2DM - combo of insulin resistance with hypertension, hyperlipidemia, procoagulant state, and obesity
34
clinical manifestations associated with metabolic syndrome
- visceral obesity - insulin resistance - high triglycerides - HTN - low HDL cholesterol
35
in order to have metabolic syndrome you need to have at least three of the following...
- fasting glucose >110 - abdominal waist >40 inches (men) and > 35 in (women) - triglyceride level > 150 - HDL < 40 (men) and < 50 (women) - blood pressure > 130/85
36
hyperosmolar hyperglycemic state (HHS)
- hyperglycemia without the presence of ketone bodies - more common in T2DM due to the fact that insulin is present enough to prevent breakdown of fats into ketone bodies - osmotic diuresis as well which results in extreme dehydration and altered level of consciousness
37
DKA vs HHS s/s
- DKA = polyuria, dyspnea, N/V | - HHS = polyuria, polydipsia, confusion, lethargy
38
four major classes of oral antidiabetic meds
- sulfonylureas - biguanides (metformin) - glitazones - glucosidase inhibitors
39
sulfonylureas
- long half life, so d/c 24-48 hours before surgery - initial treatment for T2DM - MOA = stimulate insulin secretion from pancreatic beta cells - second generation = glyburide and glipizide, which are more potent and have hypoglycemia as side effect
40
sulfonylureas harmful cardiac side effects
-may potentially inhibit myocardial protection by decreasing ATP channels in myocardium which leads to a larger myocardial infarction
41
Biguanides (metformin)
- decrease hepatic gluconeogenesis and enhance glucose utilization across cell membranes - most serious SE = lactic acidosis; this can occur if too much metformin accumulates due to acute or chronic dehydration
42
how much insulin does an adult secrete per day
50 units
43
insulin
- most important anabolic hormone - facilitates glucose and potassium into the adipose and muscle cells, therefore increasing glycogen, protein and fatty acid synthesis - decreases glycogenolysis and gluconeogenesis, lipolysis and catabolism
44
intermediate acting insulin
- NPH - lente - lispro protamine
45
short acting insulin
regular
46
rapid acting insulin
- lispro | - aspart
47
long acting insulin
- glargine (lantus) | - ultralente
48
anesthetic management goals for DM
- aggressive preop glucose control associated with less infection, improved wound healing and decrease in morbidity and mortality - maintain glycemic control - avoid further deterioration of pre-existing end organ damage - optimize electrolyte abnormalities prior to surgery - cervical spine mobility assessed preop - difficult intubation in up to 30% of T1DM
49
insulinoma
- benign pancreatic tumors that occur in women twice as much as men - tumor on pancreas that secretes LOTS of insulin - diagnosis made by whipple's triad
50
whipple's triad
- hypoglycemia with fasting - glucose of less than 50 with symptoms - relief of symptoms with glucose administration
51
treatment insulinoma
- surgical removal is definitive treatment | - preoperatively patient is treated with diazoxide (inhibits insulin release from beta cells)
52
intraoperative management of insulinoma
- first hypoglycemia may occur then hyperglycemia after tumor removal - important to monitor blood glucose levels because GA can mask s/s of hypoglycemia
53
S/S diabetic neuropathy
- HTN - painless myocardial ischemia - reduced HR to atropine or propranolol (diabetic autonomic neuropathy) - resting tachycardia - lack of sweating - may limit ability of patient to compensate and predispose patient to CV instability (ex post induction hypotension and sudden cardiac death)
54
intraoperative blood glucose management
- goal = avoid hypoglycemia while keeping blood glucose below 180 mg/dL - stress of surgery causes hyperglycemia through increase in counter regulatory hormones and inflammatory mediators
55
what is hyperglycemia in the perioperative period associated with?
- infection - poor wound healing - increased mortality - worse neurologic outcomes