Endocrine Flashcards

1
Q

Why may diabetes patients have a difficult airway? (2)

A

• Glycosylation of temperomandibular junction (limited mouth opening) and cervical spine (limited extension)
• features of autonomic dysfunction (alert you to Cv instability and aspiration risk intra-op)

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2
Q

Glucose goal for diabetics intra -op?

A

6-10 mmol/l

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3
Q

Treatment DKA? (5)

A

•1-2L ns iv bolus followed by 200-500 ml/hr
• insulin 0,1 u/kg/h iv infusion
• replace k because insulin drives it ( and glucose) intracellularly
• once plasma glucose 14, start d5W infusion.
• treat precipitating cause

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4
Q

Name 4 treatment options for hyperthyroidism

A

• Carbimazole (inhibit thyroid hormone systhesis)
• propranolol (inhibit t4 to t3 conversion, treat symptoms)
• radioactive iodine (thyroid ablation)
• thyroidectomy

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5
Q

When can thyroid disease patients have elective surgery?

A

Only when euthyroid clinically and biochemically!

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6
Q

Which special precautions and contraindications must be followed intra-op for hyperthyroid patients? (4)

A

• Avoid sympathetic stimulation! (Blunt intubation response) - ketamine contraindicated (increase metabolic rate)
• expect labile blood pressures
• careful eye care due to exophthalmos
• no increase in anaesthetic requirements

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7
Q

Treatment thyroid storm? (5)

A

• Propothiouracil (decrease production thyroid hormone)
• potassium iodide (decrease secretion)
• esmolol (iv beta blocker)
• cortisol
• active cooling
Medical emergency! Present 6-24h post op

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8
Q

What may cause airway obstruction in hyperthyroid patients post-op? (3)

A

• neck haematoma
• recurrent laryngeal nerve injury
• tracheomalacia

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9
Q

Which special precautions and contraindications must be followed intra-op for hypothyroid patients? (2)

A

• More prone to hypotension (decreased co, blunt baroreflex, decreased intravascular volume) (consider invasive bp monitor)
• consider co-existing primary adrenal insufficiency if hypotension persist (treat with cortisol)

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10
Q

Name 4 possible post-op complications hypothyroid patients

A

• Delayed emergence due to respiratory depression
• hypothermia
• myxedema coma: impaired loc, hypoventilation, hypothermia, hypo na, Ccf
Slow drug biotransformation
Fluctuating BP

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11
Q

Name 6 anatomical differences in obese patients that may make anaesthesia difficult

A

• Difficult BMv (bones)
• difficult intubation (increased risk cricothyroidotomy, also difficult)
• difficult venous access
• difficult regional anaesthesia
• difficult monitoring
• careful positioning - small operating table etc

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12
Q

Name 4 cardiovascular physiological differences in obese patients that may make anaesthesia difficult

A

• associated comorbids of metabolic syndrome
• increase risk IHD
• OSA: cause pulmonary ht and RH failure
• increase blood volume and cardiac output (0,1L/min/kg of adipose tissue)

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13
Q

Name 6 respiratory physiological differences in obese patients that may make anaesthesia difficult

A

• Increased oxygen consumption and CO2 production therefore desaturate easily and quickly
• increase mv due to increase metabolic rate
• decrease FRC due to diaphragm pushed cephalad
• decreased chest wall compliance (restrictive lung disease)
•OSA
• obesity hypoventilation syndrome

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14
Q

Name the stop-bang criteria for OSA and interpretation

A

4 or more:
• Snoring
• Tiredness
• observed apnoea
• pressure ht
• BMI >30
• age >50
• neck circumference >45 cm
• gender male

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15
Q

Name 2 gastrointestinal physiological differences in obese patients that may make anaesthesia difficult

A

• Hiatus hernia, gord, delayed gastric emptying all causing increased risk aspiration
. Fatty infiltration liver affecting drug metabolism

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16
Q

Name 3 cardiovascular risks of DM

A

Cardiac failure
Hypertension
Silent IHD

17
Q

Name 7 clinical signs of autonomic neuropathy in DM

A

Resting tachycardia
Ortho static hypotension
HT
Lack heart rate variability
Lack sweating
Impotence
Early satiety (decreased stomach emptying time)

These patients are at high risk of aspiration.

18
Q

What does “stiff Hand syndrome” (positive prayer sign), a complication of DM, imply to the anaesthetist ?

A

Difficult intubation because C spine is immobile

19
Q

Pre-op investigations for diabetics? (4)

A

• plasma/capillary glucose
• hba1c
. ECG
• uke (end organ damage)

20
Q

Normal BMI?

A

18,5-25

21
Q

Name 3 operative complications and cautions caused by OSA

A

• Increased Perioperative complications eg hypoxia, arrhythmia, mi, pulmonary edema, stroke
• vulnerable to sedatives and opioids
• may require cpap post-op

22
Q

Pre-op management obesity? (2)

A

• Aspiration prophylaxis nb (higher risk due to hiatus hernias, gord, delayed emptying)
• avoid opioids- make respiratory depression worse in these patients
Optimise comorbidities

23
Q

Name 3 post-op complications in obese

A

• Respiratory failure: give supplementary oxygen or cpap, adequate analgesia, non-sedating drugs and early mobilization
• DVT
• wound sepsis

24
Q

Name 4 post-op aims in diabetics

A

• early resumption of oral intake
• early resumption oral medication
• prevent and treat PONV
• manage pain
• continue glucose monitoring

25
Q

Which medications must be stopped or changed pre-op in diabetics?

A

• Stop biguanides (metformin) on day- risk lactic acidosis
. Stop secretogogues (sulfonylureas) - risk hypoglycaemia
• change to sliding scale insulin for the day and limit fasting as much as possible

26
Q

What can be given to diabetics intra-op to maintain normoglycaemia? (3)

A

. Bolus: actrapid iv (insulin): formula for units to use = (glucose - 6) x 0,5
! • continuous infusion: alberti/gik regime: one iv bag- glucose 10%, insulin 10 u,k 10 mmol (to avoid hypoK, insulin drive K and glucose IC)
• continuous: Ammon regime - two bags- glucose and K in one, insulin in another

27
Q

End points of treatment for DKA before bring pts to theatre? (4)

A

• Normal ph
• no ketonuria
• normal K
• glucose <14 mmol/
(Cases of acute haemorrhage, septic shock, sepsis may not allow for this so continue resus intra-op )

28
Q

Name 3 causes dKa

A

• Infection (sepsis!)
• defaulting insulin
• first time presentation

29
Q

Best way to manage airway in hyperthyroidism, especially in goitre?

A

Awake fibreoptic Intubation

30
Q

Name 4 post-op complications in hyperthyroidism after thyroid surgery

A

• Thyroid storm: medical emergency presenting 6-24 h post-op with hyper pyrexia, tachycardia, altered loc, hypotension
• airway obstruction: due to neck haematoma, recurrent laryngeal nerve injury or tracheomalacia (collapse trachea)
• hypocalcaemia: accidental parathyroid excision
• preuemothorax (uncommon)

31
Q

Name 2 pre-op considerations in thyroid patients

A

• Benzo. Patients are prone to anxiety, especially hyperthyroid
• omit thyroid medication on day only (short half life so no need to stop earlier)

32
Q

Treatment myxedema coma?

A

Iv T3

33
Q

Which patients need lower MAP?

A

Hyperthermia