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Coexisting conditions > Endocrine > Flashcards

Endocrine Flashcards

1
Q

What are the symptoms of hyperthyroid disease?

What is an example of a hyperthyroid disease?

A
  • Graves disease
  • Symptoms:
    • anxiety
    • fatigue
    • muacle weakness
    • weight loss
    • diarrhea
    • heat tolerance
    • diaphoresis
    • tachydysrhythmias
    • exophthalmos
    • goiter
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2
Q

What are some drugs used to treat hyperthyroidism?

A
  • beta blockers - treat symptoms
  • Antithyroid drugs- decrease thyroid production
    • Methimazole
    • carbimazole
    • propylthiouracil (PTU)
  • Iodid containing compounds
    • potassium iodide
    • Lugol’s solution
    • Lithium
    • glucocorticoids
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3
Q

What should you look for in pre-op assessment of a hyperthyroid patient?

A
  • Review of systems
  • Ideally they will be Euthyroid (check labs)
  • Assess affect of disease on CV system
    • EKG
  • Beta blockers pre-op
  • continue all other drugs as well
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4
Q

How do you take care of a pt with hyperthyroidism that needs emergent surgery?

A
  • Can’t cancel the surgery, so treat the symptoms
    • Esmolol 100-300 mcg/kg/min
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5
Q

What is thyrotoxicosis?

A

an excessive amount of circulating thyroid hormone. Normally endogenous cause, but people have been known to take thyroid medications to try to lose weight.

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6
Q

What is thyroid storm?

What is a major symptom?

What might it be confused with?

A
  • Abrupt release of circulating thyroid hormones that cause an acute appearance of the signs and symptoms of hyperthyroidism.
  • Thyroid hormones become very high
  • Major sign: marked elevation of body temperature, as high as 105-106 F
    • might be confused with: malignant hyperthermia, pheochromocytoma, neuroleptic malignant syndrom, sepsis
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7
Q

How is thyroid storm treated?

A
  • cooled IV crystalloids
  • esmolol drip
  • PTU- must go through NG
  • Potassium iodide
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8
Q

What should you included in your airway assessment of a patient with hyperthyroidism?

A
  • CT/X-rays
  • voice quality
  • swallowing
  • large goiter may cause tracheomalacia
  • Isthmus (the joining part of the thyroid) is located over 2nd and 4th tracheal rings
  • Assess for possible difficult airway
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9
Q

What medication that we use relatively frequently should be avoided in pts with hyperthyroidism? Why?

A

Anticholinergics b/c of tachycardia

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10
Q

What do you want to give your hyperthyroid patient preop?

What do you want to avoid?

A
  • Midazolam 2-5 mg
    • these patients tend to always be very anxious
  • Avoid hypercarbia because it stimulates sympathetic nervous system
  • Avoid hypoxia due to increased metabolic demands
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11
Q

How do you want to induce a hyperthyroid patient?

(when not a difficult airway?

A
  • Smooth- avoid fluctuations in BP and HR
  • Choice of induction drugs:
    • Thiopental
    • Propofol
    • etomidate- may see increases in BP, only use if they have developed cardiac issues
    • NO ketamine!
  • Muscle relaxants:
    • Depolarizer for difficult airway
    • any non-dep except for Pancuronium d/t SNS response
    • want 0/4 twitches
  • Lidocaine/LTA
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12
Q

What equipment might you want for intubation of a pt for a thyroid surgery?

A
  • Reinforced tube- for any head or neck surgery
  • RAE tube- for nasal intubation, some surgeons will have a preference
  • Extensions to tubing to provide surgical access
    • head of bed may be on opposite side of OR
  • Difficult airway cart handy
  • Be prepared to REALLY tape that tube!!
    • benzoin, pink tape, opsite
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13
Q

When preparing your patient for the surgery (after induction) make sure you have the _____ and _____ protected.

A

Eyes and nose

  • Use lacrilube, padding, forehead pad
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14
Q

How will your patient be positioned for a thyroidectomy?

What are some considerations for this?

A
  • Supine, arms tucked
  • Have an IV in each arm
    • b/c of limited access from arms being tucked
    • add extra extension tubing and have a port access within reach
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15
Q

What is the goal during maintenance of a pt with hyperthyroid?

How might this pt respond to the medications you administer?

A
  • Goal: Avoid stimulating SNS
  • Pt may have accelerated drug metabolism
    • not confirmed in studies
    • clinically relevant d/t increased CO
    • Hyperthermia causes 5% increase in MAC seen with 1 degree increase in body temp >37 degrees
  • Local anesthetic with epi should be avoided
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16
Q

What should you monitor during the maintenance phase of anesthesia for a hyperthyroid patient?

A
  • Look for early signs of SNS stimulation
  • monitor temp
    • may need cooling
  • Eye protection- frequent checks and make sure equipment is kept off the face
  • IV access- infiltration?
  • Muscle relaxants- may have a prolonged response
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17
Q

How will you treat hypotension in a hyperthyroid patient?

A
  • They will have an exaggerated response to pressors!
    • Try to avoid
    • decrease anesthetic
    • give fluids
    • If you must, first choice is a very low dose of phenylephrine (start at 50)
18
Q

What is the concern with emergence for a hyperthyroid patient?

A
  • Concern that the vocal cords may be paralyzed
    • may do laryngoscopic view immediately after extubating to make sure they arent
    • damage to abductor fibers of recurrent laryngeal nerve
    • Bilateral paralysis = obsturction (reintubate)
    • unilateral = hoarseness
  • tracheomalacia possible- weak rings could collapse
  • Extubate awake but NO bucking
19
Q

What are some post-op concerns for a hyperthyroid patient?

A
  • Thyroid storm (medical emergency)
  • After a thyroidectomy:
    • airway obstruction
      • recurrent laryngeal nerve damage
    • tracheomalacia
    • hemorrhage
    • hypoparathyroidism (hypocalcemia)
20
Q

What symptoms would you expect with hypothyroidism?

A
  • bradycardia
  • decreased CO, SV, and contractility
  • increased SVR, systemic htn, narrow pulse pressure
  • CHF
  • decreased response to hypoxia and hypercapnia
  • inappropriate secretion of ADH
    • hyponatremia and water rentention
21
Q

What challenges would you consider with a hypothyroid patient regarding

airway?

CV?

GI?

A
  • Airway:
    • goiter- possibly difficult airway
    • Macroglossia (puffy face)
  • Cardiac/vascular
    • bradycardia and decreased SV
    • cold intolerance causing peripheral vasoconstriction to conserve heat
  • GI
    • delayed gastric emptying (RSI)
22
Q

What are some adverse responses a hypothyroid patient may have to anesthesia?

A
  • increased sensitivity to depressants
  • hypodynamic CV system
  • slow metabolism
  • unresponsive baroreceptor reflex
  • impaired ventilatory response to low O2 or high CO2
  • hypovolemia
  • anemia
  • hypoglycemia
23
Q

What should you do for the hypothyroid patient preoperatively?

A
  • Replacement therapy- consider postponing if necessary
  • Cortisol- commonly required for adrenal insufficiency
    • especially for uncorrectable hypotension
  • Caution with benzos- avoid or half the dose
  • fluid replacement
  • delayed gastric emptying
    • RSI?
24
Q

How will a hypothyroid patient respond to regional?

A
  • They are very hypovolemic, will require lots of fluid to handle the sympathomectomy. If they have decreased CO (cardiac function?), they may not tolerate the fluids you would have to give them
  • Peripheral nerve block- could decrease dose of LA
    • metabolism may be delayed
    • increased risk for toxicity
25
Q

For a hyperthyroid patient, you would want the OR _____, with a hypothyroid patient, you want the OR ______.

A

hyper- cold

hypo- warm

26
Q

What induction medications would be good for a hypothyroid patient?

A
  • Ketamine is good
  • Thiopental- use low end of dosing
  • proporol- only use very small doses
    • potential for hypotension, esp if hypovolemic
  • Consider rapid sequence for delayed gastric emptying
27
Q

What do you need to consider regarding intubation of a hypothyroid pt?

A
  • May have goiter = difficult airway
  • May have prolonged response to muscle relaxants d/t slower metabolism
    • use PNS!
  • RSI- succ
28
Q

What do you need to consider during maintenance of a pt with hypothyroidism?

A
  • N20 alone or with low dose benzos, opioids, ketamine
    • don’t use as much anymore b/c using N2O prevents us from giving enough O2
    • Also opioids cause resp dep
  • choose VA that are shorter acting- VA used more than balanced technique
  • Maintain normothermia
  • Controlled ventilations
  • Expect prolonged response to muscle relaxants
29
Q

What are you on the lookout for when monitoring a hypothyroid patient?

A
  • Early recognition of
    • cardiac depression
    • CHF
    • hypothermia
30
Q

How will you treat hypotension in a hypothyroid patient?

A
  • Ephedrine 2.5-5 mg IV
    • also lighten anesthetic
    • fluid, but careful if pt has cardiac issues
31
Q

What challenges do you expect in the emergence of a hypothyroid patient?

A
  • Recovery may be delayed
    • prolonged somnolence
    • difficult to wean off ventilator
  • hypothermic
    • delay muscle relaxant metabolism
32
Q

What are the symptoms of hyperparathyroid disease?

A
  • hypercalcemia
  • skeletal muscle weakness
  • prolonged PR interval, short QT
  • systemic hypertension
  • anemia
  • polyuria/polydipsia
  • decreased GFR
  • kidney stones
  • vomiting, abd pain
  • PUD
  • pancreatitis
  • there are more…. so many more
33
Q

What is the preop management of hyperparathyroid?

A
  • manage hypercalcemia
  • saline infusion 150 ml/hr with loop diuretics for hymptomatic hypercalcemia
    • inhibits Na and therefore Ca reabsorption in loop of henle
34
Q

Anesthetic management of hyperparathyroid pt for parathyroid removal

meds

intubation

positioning

IV access

A
  • Meds- no specific anesthetic indicated
    • Pt will be somnnolent- reduce induction meds
    • personality changes- avoid ketamine
  • Intubation-
    • armored or RAE tube with extension
  • Positioning
    • arms to sides for head and neck surgery
    • pad really well d/t demineralizaiton of bones
  • IV access- extension tubing
    • maintain hydration- no IV fluids with calcium
    • monitor UOP
35
Q

How do you expect a hyperparathyroid patient to respond to NMB?

A
  • They will have unpredictable responses d/t increased sensitivity and muscle weakness
    • decrease dose
    • use PNS!
  • Co-existing renal dysfunction- decreased GFR and stones
    • avoid sevo and enflurane
36
Q

What is the major electrolyte imbalance you would see in hypoparathyroidism?

What are the acute and chronic symptoms?

A
  • hypocalcemia
  • Chronic
    • fatigue and muscle cramps
    • prolonged QT, normal QRS, PR, and rhythm
    • lethargy
    • personality changes
  • Acute- removal with thyroidectomy
    • oral parasthesias
    • restlessness
    • neuromuscular irritability
    • +chvostek sign, + Trousseau’s sign
    • airway stridor
37
Q

What is Chvostek’s sign?

A
  • Occurs with hypoparathyroidism; usually inadvertent removal of parathyroid glands during thyroidectomy
  • Chvostek’s sign is contraction of the muscles of the eye, mouth or nose, elicited by tapping along the course of the facial nerve
    • the examiner taps gently over the facial nerve in front of the ear
38
Q

What is Trousseau’s sign?

A
  • Occurs with inadvertent removal of parathyroid glands
  • Compression of the forearm produces a spasm of the hand and wrist
    • The thumb is adducted, the fingers bunched, and the wrist flexed
  • from neuromuscular excitability d/t hypocalcemia
39
Q

How do you manage a hypoparathyroid patient preoperatively?

A
  • Infusion of 10 ml of 10% Ca gluconate until symptoms of neuromuscular irritability dissipate
  • Thiazide diuretics
    • Na depletion with proportional excretion of K. Increases serum Ca concentration
  • Check labs
40
Q

HOw do you want to induce a hypoparathyroid patient?

meds

intubation

positioning

access

A
  • Meds- dose on low end, already lethargic
  • Intubation- armored or RAE
  • Positioning
    • arms to sides
    • Osteitis fibrosa cystica- leak of Ca from bone leads to degeneration
  • IV access w/ extension tubing
41
Q

What are your “goals” for anesthetic management of the hypoparathyroid patient?

A
  • Avoid further decreases in Ca
    • no rapid and massive blood transfusions
    • no hyperventilation- will drive Ca intracellular
  • Administer Ca
    • 1-4 gm calcium chloride/calcium gluconate IV and correct other electrolytes

Coexisting conditions (34 decks)

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