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6901 > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Hormone function and types of hormones (3)

A

Function: Signals molecules or chemical messengers that transport information from one set of cells (endocrine) to another (target)
Types:
-Peptide/protein (insulin, GH, ADH, angiotensin, EPO)
-Amine/amino (catecholamines, thyroxine)
-Lipids (steroid, cortisone, aldosterone, estrogen)

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2
Q

Hormone receptors

A

Peptide/protein
-Receptor site on cell surface is activated and generates 2nd receptor (cAMP used by vaso, TSH, parathyroid hormone)
Lipid
-Attracts specific hormone, lipophilic, diffuse into the cell (thyroid and steroid hormones)

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3
Q

Hormone regulation (3 control mechanisms)

A
  • Neural controls (pain, smell, taste)
  • Biorhythms (circadian)
  • Feedback
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4
Q

Endocrine system is involved in regulation of ____

A

Behavior, growth, metabolism, fluid status, development, reproduction

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5
Q

Endocrine vs autocrine vs paracrine

A

Hormone enters…

  • Endocrine: blood, acts at distant site
  • Autocrine: at site of origin
  • Paracrine: adjacent to site of origin
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6
Q

Endocrine glands

A 
Pituitary
Thyroid
Parathyroid
Adrenal
Pancreas
Ovaries
Testes
Placenta
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7
Q

Body functions modified by the pituitary gland

A

Homeostatic
Developmental
Metabolic
Reproductive

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8
Q

Pituitary glad located ___ connected to ___

A

Located at base of brain

Connected to hypothalamus

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9
Q

Anterior vs posterior pituitary communication with hypothalamus

A

Anterior:
-Via vascular system
Posterior:
-Via neural pathways
Hypothalamus connection controls pituitary hormone secretion
-No BBB between the two so feedback/communication can occur

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10
Q

6 hormones secreted by anterior pituitary

A

Growth hormone (GH)
Adrenocorticotropic hormone (ACTH)
-Cortisol/androgenic hormone release from adrenal cortex
Thyroid-stimulating hormone (TSH)
Follicle-stimulating hormone (FSH)
-Ovarian follicle development, spermatogenesis
Luteinizing hormone (LH)
-Ovulation, corpus luteum development, testosterone production
Prolactin
-Mammary gland development, milk production
-Inhibits synthesis/secretions of LH, FSH

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11
Q

Causes of anterior pituitary hyposecretion

A
  • Large nonfunctional pituitary tumors - compress and destroy normal cells
  • Postpartum shock, irradiation, trauma, hypophysectomy
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12
Q

Panhypopituitarism

A

Lack of pituitary hormones

  • More common than a decrease in a single ant pit hormone
  • > decreased thyroid function d/t decreased TSH
  • > Decreased glucocorticoid production (by adrenal cortex) d/t decreased ACTH
  • > Depressed sexual development and function d/t decreased gonadotropic hormone secretion
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13
Q

Treatment of pituitary tumor

A

Surgical removal

  • Transphenoidal (nasal)
  • Need thyroid hormone replacement and steroids peri-op
  • May get diabetes insipidus after removal (give vasopressin)
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14
Q

Anterior pituitary hypersecretion

A

Most commonly tumors secrete prolactin, ACTH, or GH

  • Prolactin -> infertility, amenorrhea, decreased libido (treat with dopamine agonist-bromocriptine)
  • ACTH -> Cushings
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15
Q

Growth hormone

A

Hypothalamus regulates GH activity (negative feedback)

  • Increased secretion in childhood, more in adolescence, plateaus in adulthood and decreases in old age
  • Increased by stress, hypoglycemia, exercise, and deep sleep
  • Increases blood glucose levels (decreases sensitivity of cells to insulin by inhibiting glucose uptake into cells
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16
Q

GH hyposecretion vs hypersecretions

A

Hyposecretion
-Dwarfism, hypoglycemia
Hypersecretion
-Usually caused by GH secreting pituitary adenoma
-Acromegaly -> thick large bones, enlarged organs (cardiomyopathy, HTN, atherosclerosis, LVH), increased lung volumes (VQ mismatch, increased extrathoracic obstruction), coarse facial features
-Gigantism -> if GH is elevated before adolescence, grow to 8-9 feet
-Glucose intolerance, diabetes (GH antagonist to insulin)
-Treatment: Remove pituitary tumor

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17
Q

Anesthetic plan for GH hypersecretion pituiraty tumor removal

A

Examine airway

  • Difficult mask fit and DL due to tissue overgrowth and macroglossia
  • May need smaller ETT - vocal cord enlargement
  • Extubate alert
  • Pre-op glucose and lytes
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18
Q

Posterior pituitary hormones (2)

A

Antidiuretic hormone (vasopressin, ADH)
-Controls water excretion/reabsorption in kidney
-Regulates serum osmolarity
Oxytocin
-Stimulates milk ejection during lactation
-Uterine smooth muscle contraction
-Derivatives used to induce labor/decrease postpartum bleeding

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19
Q

ADH stimulation

A

When plasma osmolarity is 284mOsm/L
-Normal 285-290
10-20% decrease in plasma volume or BP
-Baroreceptors send signal via vagal/glossopharyngeal nerves to hypothalamus -> hypothalamus increases ADH synthesis and release
Pain, emotional stress, nausea, hemorrhage

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20
Q

Diabetes insipidus

A

=Low ADH neurogenic (or inability of renal ducts to respond nephrogenic)

  • Polyuria, polydipsia
  • > Dehydration, hypernatremia
  • Hyperreflexia, weak, lethargic, seizures, coma
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21
Q

Diabetes insipidus anesthetic considerations and treatment

A

Assess fluid status, electrolytes
-Surgery increases ADH release so pre-op vasopressin isn’t usually necessary with partial DI
-Monitor plasma osm, UOP, serum Na q1h
-Give isotonic fluids until serum osm=290, then hypotonic
Treatment (complete DI)
-Meds that increase ADH release or increase receptor response to ADH
-Short term=vasopressin
-Long term=desmopressin

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22
Q

Syndrome of inappropriate anti-diuretic hormone (SIADH) (characteristics, anesthetic consideration, treatment)

A

=High ADH levels
-Water reabsorbed in tubules even when hypoosmolar
-Low UOP -> water intoxication, hyponatremia -> brain edema
Slow emergence
Treatment
-Mild, without s/s of hyponatremia: fluid restriction (800mL/day)
-More severe: hypertonic saline with Lasix
-Correct Na levels slowly

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23
Q

Thyroid gland

A

Function
-Secrete thyroid hormones to regulate cellular metabolism and calcium balance
Nerves in proximity
-Recurrent laryngeal nerve and external motor branch of superior laryngeal nerve

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24
Q

3 hormones secreted by the thyroid gland

A 
T4
-Thyroxine
-93% of hormone
-less potent in blood
-prehormone: converted to T3 at tissue sites
T3
-Triiodothyonine
-7% of hormone
-more potent in blood
Calcitonin
-Regulates calcium short-term
Dependent on iodine for production
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25
Q

Actions of thyroid hormone

A

Increased metabolic rate, O2 consumption, heat production
-Secondarily increased heart, lung, kidney function
T3 plays a role in growth and development

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26
Q

Graves disease or thyrotoxicosis

A

Hyperthyroidism
S/S: Goiter, ST, anxiety, tremor, heat intolerance, insomnia, weight loss, a fib, skeletal muscle weakness
Dx: decreased TSH, increased T4
Tx:
-Meds to inhibit hormone synthesis (methimazole, propylthiouracil, carbimazole)
-Prevent hormone release (potassium, sodium iodine)
-Mask adrenergic overactivity (propranolol, atenolol)
-Destroy thyroid cell function (radioactive iodine)
-Surgery: subtotal thyroidectomy

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27
Q

Anesthetic management for hyperthyroid

A

Untreated symptomatic patients should only go to OR if life threatening
-Continue antithyroid meds and BB through morning of surgery to decrease SNS
-Esmolol inhibits T4 to T3
Assess airway for tracheal deviation from thyroid enlargement
*No ketamine, atropine, pancuronium (SNS stimulation)
-Deep anesthesia before intubation
-May need more inhalational agents (increased CO, blood volume)
-Treat intraop hypotension with direct pressors (phenylephrine)
*ETT with NIM (electrodes on VCs) to assess recurrent laryngeal nerve

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28
Q

Thyroid storm

A

Life-threatening
Caused by acute stress in undiagnosed or untreated hyperthyroid patient
-May occur anytime periop, more likely 6-18 hours posto
-Different from MH: No muscle rigidity, elevated creatinine kinase, respiratory acidosis
S/Sx:
-Tachycardia, agitation, a fib, fever (>38.5)
Tx:
-IV hydration with glucose
-Cooling/Tylenol
-Beta blockers
-Potassium iodide (block T4 and T3 release)
-Correct electrolytes/acid base imbalance

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29
Q

Recurrent laryngeal nerve palsy

A

Postop thyroidectomy complication

  • Decreased occurance with NIM use
  • Unilateral-hoarseness
  • Bilateral-aphonia, stridor -> reintubate
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30
Q

Thyrotoxicosis vs MH

A 
Thyrotoxicosis
-Elevated HR/BP, A fib, CHF
-Hyperprexia (fever), acidosis 
MH
-Unexplained sudden increase in ETCO2
-Elevated HR, trismus (lockjaw), rapid temp rise, mottling, cyanosis
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31
Q

Hypothyroidism (etiology, s/sx, dx, tx)

A 
Hashimoto thyroiditis
Etiology
-Autoimmune mediated inflammation
-Iodine deficiency
-Extreme=myxedema
S/Sx
-Lethargy, hypotension, bradycardia, CHF, gastroparesis, hypothermia, hypoventilation, hyponatremia, poor mentation
Dx:
Primary
-Decreased T4 and/or T3
-Increased TSH
Secondary
-Decreased T4, T3, TSH
Tx
-Replace T4: synthroid
32
Q

Preop anesthetic considerations for hypothyroid

A

Careful airway evaluation due to enlarged thyroid gland, enlarged tongue, myxedematous infiltration of VCs
-Severe hypothyroid a/w multiple complications with anesthesia - myocardial and baroreceptor function may be depressed

33
Q

Intraop management for hypothyroid

A
  • No effect on MAC
  • Respiratory depression after opioids may be increased: assess for large tongue, goiter hypoxia and hypercarbia (ventilatory response to hypoxia/hypercarbia may be depressed)
  • Hypotension/myocardial depressed from inhalation agents may be increased, plasma volume reduced
  • Ketamine good for induction
  • Body temp closely for hypothermia
  • May be sensitive to NDMRs if experiencing muscle weakness
  • Slower GI emptying - aspiration risk (RSI?)
  • Potential adrenal insufficiency - periop cortisol
34
Q

Myxedemia

A

End stage untreated severe hypothyroidism

  • Hypothermic, hypoventilation, hyponatremic
  • Only do surgery if lifesaving
35
Q

Parathyroid hormone

A

Released in response to low serum ionized calcium

  • Or hyperphosphatemia or hypomagnesemia
  • Provides negative feedback control of calcium
  • Increases extracellular calcium, decreases extracellular phosphate
  • Increases renal calcium absorption and phosphate excretion
36
Q

Calcitonin

A

Hormone secreted from thyroid in response to elevated ionized calcium, has weak effect (opposite of PTH)

37
Q

Parathyroid dysfunction

A

Affects bone, intestinal tract (Ca absorption), kidney (VitD formation, Ca reabsorption, phosphate excretion)
Hyperparathyroid -> hypercalcemia
-HTN, ventricular dysrhythmias, shortened QT, impaired renal concentration, muscle weakness, osteoporosis, mental status changes
-Calcifications in organs (pancreas, kidney, heart, stomach)

38
Q

Treatment of severe hypercalcemia during surgery

A

> 13-16
Isotonic saline and loop diuretic (Lasix)
-Avoid hypoventilation - hyperventilation/alkalosis decreases active ionized calcium (decreases calcium and K)

39
Q

Bilateral RLN injury during parathyroidectomy

A

Requires immediate reintubation

40
Q

Insulin effects on cells

A

Bind to receptor (peptide hormone)

  • Protein activation cascades start
  • Glut 4 transporter translocated to plasma membrane, influx of glucose
  • Glycolysis
  • Fatty acid synthesis
41
Q

DM Type 1 (% of all DM, cause, characterized, risks)

A

5-10% of all DM cases

  • Autoimmune destruction of beta cells in the pancreas
  • Total deficiency in insulin production
  • At risk for DKA and rarely HHNC
42
Q

DM 2 characteristic

A

Impaired insulin secretion, peripheral insulin resistance, excessive hepatic glucose production (environmental, genetic, lifestyle factors)

43
Q

DM periop (impact on recovery, highest risk, concerns)

A

DM patients will spend 50% more time in the hospital recovering from surgery

  • Undiagnosed DM=higher risk
  • Concerns: End-organ complications, glucose-lower regimen
44
Q

Autonomic neuropathy in DM patients

A 
Impaired gastric emptying
-Aspiration risk
-Slow gastric emptying
-Reflux esophagitis
-H2 blocker or metoclopramide preop, RSI
Dysfunction of cardiac vagus nerve
-Orthostatic hypotension, tachycardia, dysrhythmias
Higher morbidity/mortality
45
Q

Oral hypoglycemic (biggest flag, risks, preop holding)

A

Metformin

  • Risk for hypotension and renal hypoperfusion -> lactic acidosis
  • Hold 48 hours prior to surgery (controversial)
  • New guidelines: Hold for 24 hours if renal compromise or giving contrast during surgery
46
Q

DM medication instructions preop for Type I vs II vs insulin pump

A

DM I
-Dependent on insulin, reduce dose
-1/2 insulin PM before, no insulin or decreased dose AM
DM II
-1/2 insulin PM, none AM of surgery
Insulin pump
-Talk with patients, know settings, check site
-Decrease rate in PM and basal rate intraop
-Caution with radiation, electrocautery
-Hold all oral hypoglycemics preop
-Hold all non-insulin injectable medications DOS

47
Q

Blood sugar goal during anesthesia

A

Mildly hyperglycemic (s/sx of hypoglycemia are masked)

  • 80-180
  • Check q1h
48
Q

Protamine and NPH

A

Protamine sulfate anaphylaxis can occur in patients taking NPH or protamine zinc insulin

49
Q

Hypoglycemia treatment (& how much 15mL D50 raises glucose)

A

25-50mL D50 followed by D5 gtt

  • 70kg pt: 15mL D50 increase blood glucose by 30mg/dL
  • 1mL D50 increases BG by 2mg/dL
50
Q

Mortality for DKA vs HHS

A

Higher for HHS, affects the elderly/DM II patients more after an acute illness

51
Q

Goal plasma osmolarity for HHS treatment

A

Diagnosis=>330mOsm/L
Give fluids
-(1/2 NS) if >320mOsm/L until <320, then NS
-Careful when giving fluids, patients typically elderly and can get cerebral edema or CHF

52
Q

Adrenal cortex hormones

A 
Mineralcorticoids
-Aldosterone
-Regulate extracellular volume and potassium (Na reabsorption, K secretion)
Glucocorticoids 
-Cortisol
-ACTH stimulates synthesis
-Maintains/regulates immune/circulatory function
Androgen hormones
-Dehydroepiandrosterone
53
Q

Adrenal medulla

A

Inner part of adrenal gland

-Secretes norepi, dopamine, and epi (80% catecholamine output)

54
Q

Adrenal cortex dysfunction (types, effects, treatment)

A

Increased aldosterone production
2 types
-Primary: from adrenal adenoma (Conn syndrome), no stimulus
-Secondary: from increased renin production
-> increased urinary sodium and potassium exchange -> hyperNa, hypoK (HTN, weakness)
Tx: Remove tumor

55
Q

Adrenal cortex dysfunction anesthetic plan

A

Correct fluid/lyte (K) balance preop
Manage HTN: spironolactone (aldosterone antagonist)
Peripheral nerve stimulator for muscle relaxants, hypoK may enhance MR
-Avoid hyperventilation (decrease K more)

56
Q

Cushings syndrome

A 
Excess cortisol/glucocorticoid
-Commonly caused by superphysiologic exogenous doses of glucocorticoids for arthritis, asthma, autoimmune d/o, allergies
S/Sx: 
-Central obesity, thin extremities
-HTN
-Glucose intolerance
-Increased intravascular fluid volume, hypokalemia
-Moon face, buffalo hump
57
Q

Anesthetic management for cushing syndrome

A
  • Correct fluid/lyte imbalance preop
  • Spironolactone
  • Careful positioning (osteopenia)
  • Conservative with MR if skeletal muscle weakness
  • Thromboemboli more common
58
Q

Addisons disease

A

Adrenocortical insufficiency, decreased cortisol
-Adrenal androgen, glucocorticoid, mineralocorticoid all deficient
S/Sx: Hyperpigmentation, s/s c/w cortisol deficiency, aldosterone deficiency
Hemodynamic instability

59
Q

Adrenal medulla dysfunction

A

Pheochromocytoma
-Catecholamine secreting tumor
S/Sx:
-Paroxysmal headache, HTN, sweating, palpitations
-Unexpected intraop HTN/tachycardia can be indication of this (during manipulation of abdominal cavity)
Dx:
-Clonidine will decrease neurogenic catecholamines but not ones from pheochromocytoma

60
Q

Preop plan for pheochromocytoma

A

1: Alpha blocker, volume replacement
-1-2 weeks preop
2: Beta blocker if necessary for reflex tachycardia
-Added after several days of a-blockade
-Don’t add first because can cause vasodilation which can worsen HTN
Goals
-BP<160/90 for >24hrs
-Orthostatic hypotension (not <80/45 standing)
-<1 PVC every 5 mins
-No ST segment changes/T wave inversions on ECG for 1 week
-Hct decrease 5%: suggests adequate intravascular volume expansion, satisfactory alpha-blockade

61
Q

Intraop pheochromocytoma (equipment/monitoring, meds, what to avoid)

A 
A line
Large bore PIVs
Deep intubation (LTA kit helpful)
Foley
CVP/Swan
Anticipate labile CV
Meds
-1 Alpha blockers
-2 Beta blockers
-Nicardipine
-Magnesium sulfate
-Nitroprusside, nitroglycerine
Avoid
-Ephedrine
-Ketamine
-Hypoventilation (stimulate SNS)
-Atracurium (histamine release)
-Morphine (histamine release)
62
Q

Pheochromocytoma after tumor removal

A 
Hypotension
-d/t hypovolemia, a-blockade, tolerance to endogenous catecholamines which are now gone
Tx:
-Fluids
-Phenylephrine
-Norepi
63
Q

Multiple endocrine neoplasia (MEN)

A

Overactivity of 1 + endocrine glands
-Inherited genetic effect
MEN 1:
-Parathyroid tumors, pancreatic tumors, pituitary tumors
MEN 2a:
-Medullary thyroid cancers, pheochromocytoma, parathyroid tumors
MEN 2b:
-Medullary thyroid cancers, pheochromocytoma, mucosal neuromas*
*=most commonly occuring

64
Q

Carcinoid syndrome S/Sx

A 
Results from slow growing tumors
-Vasoactice substances are secreted from enterochromaffin cells
S/Sx depend on vasoactive substance involved) (serotonin -> vasoconstriction, kallikrein and histamine -> vasodilation)
-Right-sided heart failure (serotonin)
-Labile BP (kallikrein, histamine)
-Cutaneous flushing (kallikrein)
-Bronchospasm (kallikrein, histamine)
-Diarrhea, abdominal pain (serotonin)
65
Q

Carcinoid syndrome (Dx, Tx, preop)

A

Dx: Serotonin metabolites in urine, elevated plasma chromogranin A
Tx: Surgical removal or management or symptoms
Preop:
-H1 and H2 blockers
-Evaluate extraintestinal manifestations (AXR)
-Octreotide 2 weeks before surgery

66
Q

Octreotide and somatostatin for carcinoid syndrome

A

Octreotide
-Serotonin antagonist
-Inhibits all bioactive substances
Somatostatin
-Antagonize and suppress release of tumor products
-Binds to tumor cell receptors -> decreased secretion

67
Q

Carcinoid syndrome intraop

A

A line, large PIV, CVP

  • Avoid causing release of vasoactive substances from the tumor
  • Treat refractory hypotension with vasopressin
  • Octreotide available
  • Steroids, H2 blockers
  • Avoid histamine releasing substances (morphine, atracurium, succs)
  • Deep anesthesia (eliminate cardiac fluctuations from light anesthetic
68
Q

Hypoparathyroidism anesthetic implications

A

-Hypocalcemia
-Risk of laryngospasm
-Respiratory distress due to edema, bleeding, or bilateral RLN injury (requires immediate reintubation)
-Avoid hyperventilation
Tx: IV CaCl

69
Q

Islets of Langerhans cell types

A

Cells in pancreas
Alpha: secrete glucagon
Beta: secrete insulin

70
Q

Islet of Langerhans alpha, beta, delta cells

A

Alpha: Produce glucagon
Beta: Produce insulin
Delta: Produce somatostatin
-Inhibits GI motility and secretion of stomach acid

71
Q

Insulins anabolic action

A

Anabolic=simpler molecules->complex, builds up tissues
Glucose -> glycogen and triglycerides
And has anticatabolic effect (prevents tissue breakdown to glucose)

72
Q

6 endocrine organs that provide the endocrine component of the stress response

A

Anterior and posterior pituitary
Hypothalamus
Adrenal cortex and medulla
Pancreas

73
Q

Hormonal response to surgical stress

A 
Increased
-Cortisol, glucagon, GH, catecholamines
Decreased
-Insulin
Both
->Decreased glucose clearance and increased gluconeogenesis
74
Q

Dawn phenomenon vs somogyi effect

A

Dawn phenomenon
-GH, cortisol, glucagon secreted overnight, increased blood glucose
-Need insulin overnight to counteract this
Somogyi effect
-When too much insulin is given at HS and pt gets hypoglycemic overnight

75
Q

Insulin transport to systemic circulation

A

Produced by pancreas
~60 units/day
-First goes to liver where 20-50% is metabolized/deactivated
-When passing through liver, hepatic glucose production is suppressed

76
Q

Metformin MOA

A

Decreases hepatic glucose production
-Prevents conversion of lactate to glucose
Increases insulin sensitivity (GLUT 4 transport to cell membranes)

77
Q

IV insulin half life

A

7.5 minutes
Will be gone in 35 mins
Best to do drip

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