Endocrine Flashcards
S/s Graves’ disease/hyperthyroid
Anxiety Fatigue Muscle weakness Weight loss Diarrhea Heat tolerance Diaphoresis Tachydysrhythmias Exophthalmos Goiter
Preop prep hyperthyroid.
Check labs for euthyroid, ekg normal, bb po preop, continue all drugs
Drug tx hyperthyroid
Bb (Prop/aten/metop/nad), antithyroid (methimazole/PTu/carbimazole), iodide containing solutions (k iodide, lugols sol, lithium, glucocorticoids)
Management of hyperthyroid pt if emergent sx
Esmolol 100-300ug/kg/min gtt. Thyrotoxicosis- an excessive amt of thyroid hormone. May be an exogenous source with a normal thyroid gland.
Thyroid storm: sign, often confused with
Temp elevated as high as 105-106 f. MG, pheo, neurleptic malignant syndrome, sepsis
Thyroid storm management
Cooled crystalloid, esmolol gtt, ptu, k iodide
Airway assessment hyperthyroid
Ct, x ray, voice, swallowing, tracheomalacia from goiter, isthmus over 2-4th tracheal rings, may be difficult a/w
What to do for difficult a/w
Sedation, awake intub, a/w block, difficult a/w cart
Preop meds hyperthyroid: avoid what, give what
Anticholinergics (avoid). Give 2-5 mg versed. Avoid hypercarbia (stim sns), avoid hypoxia (inc metabolic demands)
Induction consid hyperthyroid
Pre oxygenate well (hypermetabolism), VS Normal/adequate sedation, avoid oversedation. Good drugs: thiopental, propofol. NO ketamine.
Induction equip hyperthyroid
Reinforced tube, Rae, nasal intub may be req, extensions, access to difficult a/w cart
Muscle relaxants for hyperthyroid, what else to atten sns
Depolarizers (sux). Non-dep avoid panc. Ensure complete relaxation to avoid bucking. Xylocaine iv or LTA
Positioning thyroidectomy
Supine w arms tucked. IV each arm (2nd after induction). Extension tubing
Maintenance hyperthyroid: goal, anes fx, avoid what
Goal to avoid sns stim. 5% inc MAC w each 1 degree over 37 degrees. Avoid local w epi
Monitoring for hyperthyroid
Recog sns stim, cooling devices, eye protection, iv infiltration, muscle relaxants, treat hypotension w fluids or lightening anesthesia first. Then ephedrine (exag response to direct acting drugs)
Emergence for hyperthyroid consid
Thyroidectomy- concern of VC paralysis. Damage to abductor fibers of laryngeal nerve (bilateral= obstruction, uni= hoarse). Weak rings if tracheomalacia. Awake but no bucking- xylocaine.
Possible complications after surgery w hyperthyroid
Thyroid storm (emergency), thyroidectomy: a/w obstruc from nerve damage, tracheomalacia, hemorrhage, hypoparathyroidism- hypocalcemia
Cardiac consid of hypothyroid pts
Bradycardia, dec CO/SV/contractility. Inc SVR/BP, narrow PP. CHF occasionally. Dec EKG voltage, prolonged PR/QRS/QTi. Potential for pericardial effusion and conduc abn
Hypothyroid respiratory effects
Decreased response to hypoxia and hypercapnia
Renal effects hypothyroid
SIADH, hyponatremia, inability to excrete free water
Pre op hypothyroid consid
Airway (goiter, macroglossia, puffy face). Cv: low hr, dec SV, cold intolerance, vasoconstriction peripherally. Delayed gastric emptying
Hypothyroid: possible adverse responses in anesthesia
Inc sensitivity to depressants, slow metab, unresponsive baroreceptor reflex. Dec resp to hypoxia/hypercapnia. Hypovolemia, anemic, hypoglycemia
Hypothyroid: postpone if what. Med considerations to plan for
No replacement tx/not being managed. Adrenal insuff, avoid of 1/2 dose of benzos, fluid replacement, RSI if reflux
Regional considerations for hypothyroid
Decrease dose in pn block. Metabolism of local may be delayed- toxicity possible
Induction considerations hypothyroid: room management, etc
Avoid sedation for transfer. Warm blankets. HOB up and pre ox for ventilation.
Induction drugs that are good or not for hypothyroid
Ketamine good (low dose). Thiopental- low dose. Propofol- hypotension potential
Intubation consid hypothyroid
Goiter- difficult a/w cart. Prolonged response to relaxants- titrate w nerve stim. RSI w sux
Maintenance hypothyroid
N20 or w low dose benzos/opioids/ketamine. Maintain body temp. Controlled vent.
Monitoring hypothyroid intraop: early recog of what, tx w what
Cardiac depression, CHF, hypothermia. Tx low bp w 2.5-5 mg ephedrine
Hypothyroid emergence considerations
Delayed recovery: difficulty weaning from vent, hypothermia may delay metab of muscle relaxant
Hyperparathyroidism: hallmark. NM fx. Renal fx.
Hypercalcemia. Muscle weakness. Polyuria, polydipsia, dec GFR, kidney stones
Hyperparathyroid: cv and GI fx
Prolonged PR, short QTi, htn, anemic. Vomiting, abd pain, PUD, pancreatitis
Hyperparathyroid: skeletal, NS, ocular fx
Demineralization, vertebral collapse, fractures. Somnolent, dec pain sens, psychosis. Calcifications and conjunctivitis
Hyperparathyroid: manage what preop
Hypercalcemia w nacl 150 ml/hr if symptomatic. Lasix to inhib na and ca reabs
Anes consid intraop hyperthyroid
Somnolent- less induc meds, less pain sens, avoid ketamine. Intub- Rae tubing, extensions. Extension on IV tubing, no LR (Ca), monitor UOP
Hyperparathyroid: muscle relaxant consid, renal consid w VA choice
Unpredictable response- dec dose and use stim. Avoid sevo and enflurane d/t dec GFR
Hypoparathyroidism: chronic issues
Fatigue, muscle cramps, prolonged QT, normal QRS/PR/rhythm. Tired, personality changes
Hypoparathyroidism: acute changes (w removal)
Oral parasthesias, restless, NM irritability, + chvostek’s/trousseau, a/w stridor
Chvosteks, trousseau
C- twitch of face w tap. T- compression of FA produces spasm of hand and wrist
Hypoparathyroidism pre op management
Check labs. 10 ml 10% ca gluc until symptoms go away. Thiazides diuretics deplete na and k, inc ca.
Hypoparathyroid: induction consid
Low end dosing (tired). Rae tube. IV extension.
Hypoparathyroidism: intra op management
Avoid further ca dec. No rapid/MTP, no hyperventilation. Give 1-4g ca cl/ca gluc iv
CM DM
Polydipsia/phagia/uria. Recurrent infections. Visual changes. Parasthesias, tired
IDDM anesthesia: fast, intermediate, long acting
Fast: regular/humalog/semilente. Intermediate: NPH and lente. Long: protamine zinc and ultralente
NIDDM consid: meds and what they do
Metformin- inc sensitivity to insulin. Acarbose- delays digestion of carbs. Sulfonylureas- hypoglucemia up to 50 hrs after- inc fx of barbs, tolbutamide metab from liver, chlorpropramide renal excretion dependent
Stiff joint syndrome: which disease and considerations
IDDM. Ltd joint mobility- difficult laryngoscope d/t atlanto occipital mobility dec and laryngeal rigidity
Diabetic autonomic neuropathy: effects which systems and how
Cv and GI. Ortho hypo, resting tachycardia, periph neurop, loss of HR variability, dysrhythmias, gastroparesis, alt reg of breathing, sudden death syndrome
Preop eval of DM
Type of dm, duration, daily tx. Complic: renal, nerves, gastroparesis, autonomic neuropathy, infec, htn, cv disease
Preop eval dm: what labs/tests to check specifically
Pre op ecg, lytes, a1c, stiff joint syndrome. Bg in holding area, may cancel if >300 and not normal for pt
Anesthesia consid DM
Schedule early in day, difficult intub, may do RSI, 50-100% 02 for cv disease, glucometer for bg. Avoid nephrotoxic agents, inc sens to cv depressants, may do regional. Aggressively tx Brady w epi if autonomic neurop
Reasons to do tight control
Type 1 dm. Inc healing, dec infec, Dec osmotic diuresis, dec incidence DKA
Nontight DM management
Fbg am of sx. IV d5w 100-125 ml/hr. 30-50% am insulin intermediate sq. Bg q1-2 hrs, adjust d5 accordingly. If bg >200 give iv insulin on sliding scale. 1 u drops bg 50 mg
How tight control is done
Fasting bg. D5w on pump 100-150 ml/hr. 2nd started w normal fluid. 50 u ins in 250 bag, divide hourly. Bg by 150 to get rate. Check k levels, add 20 meq to each l of glucose
Regional considerations dm
Ineffective in area of infection. Concern if autonomic neurop: peripheral neurop, hypotension
