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Endocrine Flashcards

1
Q

Effects of hyperglycemia

A

Impaired immune response leading to inc risk of infection, impaired wound healing, dehydration, electrolyte disturbances (hyperK)

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2
Q

Should an MG patient continue their pyridostigmine the morning of surgery?

A

No clear answer but continuing could help avoid resp difficulties prior to surgery.

The disadvantage however is possibility of prolonged NMB with Sux and developing cholinergic crisis.

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3
Q

How would you evaluate a patient’s Carcinoid?

A

Functional vs. non-functional
- flushing, diarrhea, bronchospasm, BP swings or palpitations, murmurs

Dx = Urinary 5-HIAA

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4
Q

What are your anesthetic concerns for a patient with Carcinoid?

A
  1. Cardiac concerns - right sided heart lesions, heart failure
  2. Pulmonary concerns - bronchospasm, dyspnea, etc
  3. Avoid triggering a crisis
    - avoid meperidine, morphine, sux, atracurium, mivacurium (histamine)
    - avoid fasciculations from sux or vigorous abdominal scrubbing
    - avoid exogenous catecholamines - epi, levo, stress, anxiety, pain, hypotension, hypothermia, laryngoscopy
    - things high in serotonin/histamine - coffee, cheese, etOH,
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5
Q

How would you evaluate a pheochromocytoma patient’s readiness for surgery?

A

Volume status - CBC for hemoconcentration
BP trends
SOB or chest pain
EKG - LVH, t-wave and ECHO esp w/ dec energy level (catecholamine induced cardiomyopathy)
Started and alpha 10-14 days–> beta blockers

Roizen criteria

  • supine BP <160/90
  • orthostatic hypotension <80/45
  • EKG w/o ST, T wave changes
  • no more than 1 PVC every 5 minutes
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6
Q

How is a Pheo diagnosed?

A

Plasma metanephrines

Urinary catecholamines
Urinary VMA

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7
Q

What drugs would you avoid in a Pheo?

A
  1. Drugs that stimulate tumor cells
    - Sux from fasiculations
    - Morphine and atracurium from histamine
  2. Drugs that inc sympathetic activity
    - atropine, ketamine, ephedrine
  3. Drugs that sensitize myocardium to catecholamines
    - halothane, droperidol, metoclopramide, ephedrine —-> HTN
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8
Q

Tx BG 356

A 
? Developed DKA - any N/V, abdominal pain
10U insulin
NS fluid replacement
Urinary and serum ketones
ABG
Anion gap
Insulin gtt to dec by 75-100 per hour (avoid cerebral edema)
Add 5% dextrose at bg250
Replace potassium, mag

Even a short delay to resolve acidosis, hypovolemia and hypokalemia reduce the risk of cardiac arrthymia and hypotension

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9
Q

Flow volume loop for large thyroid mass

A

Fixed obstruction - flattening of both inspiratory and expiratory limbs

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10
Q

How would you optimize hyperthyroid patient for surgery?

A 
Consult endocrine
Continue PTU - inhibits peripheral conversion T4->T3
Administer beta blockade (normal HR)
Glucocorticoids (dec conversion of T4)
Hydration
Normal electrolytes
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11
Q

How would you differentiate between MH, thyroid storm and NMS?

A

All manifest with tachycardia, hyperthermia and AMS

MH and NMS - metabolic acidosis, profound hypercarbia, muscle rigidity
NMS usually slower development than MH
NMS flaccid paralysis with ND-NMBS
Tx immediately with dantrolene

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12
Q

How would you treat thyroid storm?

A 
Acetaminophen 
Active cooling
Beta blockers
Fluids
Correct electrolytes
PTU
Hydrocortisone
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13
Q

Hormones produced by pituitary

A 
ACTH
Prolactin
GH
TSH
FSH
LH

ADH
Oxytocin

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14
Q

What are the mechanisms of bromocriptine and octreotide

A

Bromo - D2 agonist inhibits secretion of GH and prolactin

Octreotide - somatostatin analogue that dec release of GH

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15
Q

Systemic manifestations of RA

A

Pericardial thickening, effusion
Valve fibrosis, ischemia, diastolic dysfunction, nodules cause dysrhythmias

Pleural effusions, pulm fibrosis
neuropathies
liver and kidney dysfunctions
Dry eyes and mouth

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16
Q

Pathophysiology of myasthenia gravis

A

Antibodies or destruction of post-synaptic Ach receptors —> weakness, easy fatiguability

Ptosis, dysarthria, dysphagia, resp insufficiency, aspiration

Tx = anticholinesterase (pyridostigmine)

17
Q

Should you use sux with myasthenia gravis?

A

Can use Sux when indicated
Typically RESISTANT to sux

If on anticholinesaterase therapy, duration may be prolonged (dec plasma cholinesterase activity)

Not on therapy/undiagnosed –> profound sensitivity of ND-NMBDs

18
Q

MG patient - After getting neostigmine, resp effort improves but 45 min later complains of weakness and dyspnea. What is the cause?

A

Myasthenic crisis vs. cholinergic crisis

Give 10mg edrophonium —> improved strength, mydriasis = myasthenic

19
Q

What is Carcinoid syndrome and why doesn’t it manifest with all carcinoid tumors?

A

Complex of signs and symptoms that result when vasoactive substances are released from carcinoid tumors –> flushing, bronchoconstriction, diarrhea, right sided heart disease

Most are GI –> portal circulation and removed by liver. Syndrome develops when bypass portal system (mets to liver or outside GI tract

20
Q

How would you optimize a patient with carcinoid for surgery? Induce?

A

Diarrhea –> fluid resuscitation
Ocreotide –> dec release of vasoactive substances
Anxiolytic –> dec stress-induced release
H1, H2, steroids –> dec systemic effects of substances

Slow controlled, deep induction to avoid tumor release of vasoactive substances

21
Q

What are the signs and symptoms of thyrotoxicosis?

A 
Tachycardia
Inc CO
Dec SVR, PVR
Anxiety, agitation, tremors
Weakness, sweating, heat intolerance, weight loss
Dec TSH, Inc free T3, T4
22
Q

Cholinergic crisis vs. Anticholinergic crisis

A

Cholinergic

  • DUMBELS
  • Organophosphates
  • Tx = 2-4mg Atropine, pralidoxime

Anticholinergic

  • Hot, Blind, Mad, Dry
  • Atropine
  • Tx = Physostigmine
23
Q

Atropine dose

A

Adults

  • 0.5 - 1mg q2-3min
  • Max 3mg

Peds

  • 0.02mg/kg
  • Min 0.1mg –> max 0.5mg
  • Max 3mg total
24
Q

Flumazenil dose

A

0.2 q 15s
1mg q2min

Max 5mg

25
Q

How would you assess if a myasthenia patient is optimized for surgery?

A

I would asses for severity of her symptoms
- ocular only –> respiratory, laryngeal muscles by talking , swallowing

Any issues with previous anesthetics, prolonged intubations

Any episodes of myasthenia crisis

Stability of symptoms over past year

Assess B/L motor strength in extremities and look for pharyngeal muscle involvement

26
Q

How would you induce a MG patient? Would you use NMBs? If so, which ones? How would you dose? Would you use a twitch monitor?

A

Assuming a reassuring airway I would

  • apply monitors
  • Pre O2
  • slow controlled induction with short acting agents - remi, prop, lidocaine

I would avoid NMBs if possible because they are highly sensitive to ND-NMBDs. I would use very small dose and titrate or SUX 1.5-2mg/kg due to resistance to sux

I would use a twitch monitor recognizing that may not be reliable. Weakness is uneven and may exhibit fade baseline

27
Q

What is myasthenic crisis and what are the precipitating factors?

A

Severe bulbar or respiratory symptoms from progression of disease or other factors.

  • infection
  • surgery
  • stress
  • hypothermia
  • acidosis
  • hypoK
  • hypoMag
  • aminoglycosides
  • flouroquinlones
  • clindamycin
  • BBs
  • CCBs
  • NMBDs
  • Anticholinergics
28
Q

Post-op from Pheo resection patients BG is 35. What would you do?

A

Recheck quickly to confirm
Start D5 infusion
Verify hemodynamically and neurologically stable

Surge of insulin sensitivity following low serum catecholamine levels

29
Q

How would you address hypothyroidism pre-operatively?

A

Ideally delay until euthyroid

Inc aspiration risk
Inc sensitivity to opioids
Hypoglycemia
Hypotension
Adrenal insufficiency
Delayed emergence
30
Q

MG patient with fever pre-op, is this a concern? Would you give anti-pyretics?

A

Yes, this could be indicative of a myasthenia crisis or an infection like PNA or C.diff (common in MG).

Therefore I would order blood, sputum or stool cultures based on any other symptoms or perform a Tension test to rule out myasthenia crisis.

I would give anti-pyretics because fever can induce a MG crisis. I would verify any antibiotics are not know to cause MG crisis before administering.

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