Endocrine-Adrenal Cortex Flashcards by shay edgeston

What hormones does the adrenal cortex/gland secrete?

Corticosteroids derived from cholesterol like mineralocorticoids & glucocorticoids

Androgens

Estrogen

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What is an example of a mineralocorticoid

Aldosterone

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Role of aldosterone

Fluid & electrolyte balance by increase Na reabsorption and increasing K+, Ca+ & Mg+ excretion

Increases activity of NaK pump

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Aldosterone effects on the CV and MS system

Na & H2o retention may increase BP & CO

Muscle weakness due to K+ & Ca+ excretion

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Aldosterone has no

Glucocorticoid effect

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An example of a glucocorticoid is

Cortisol

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Glucocorticoid-cortisol metabolism…

Stimulates gluconeogenesis through protein catabolism

Carbohydrate storage as glycogen

Mobilization of fatty acids from adipose w/redistrtibution

Oxidation of fatty acids

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Glucocorticoid-cortisol balances

Fluid & electrolytes by diuresis, increasing GFR, RBF, Na reabsorption & K+ excretion (can inhibit anti-diuretic)

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Glucocorticoid-cortisol effects on endocrine

Increases secretion of GH and synthesis & effects of epi

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Glucocorticoid-cortisol CV effects

High levels can induce HTN & increased responsiveness to vasopressors

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Glucocorticoid-cortisol MS effects

Muscle wasting, bone loss, & reduced bone remodeling

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Glucocorticoid-cortisol CNS effects

Increased excitability, mood changes, dementia, & cognitive depression

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Glucocorticoid-cortisol hematologic effects

Increases serum HGB & RBC

Decreases lymphocytes, eosinophils, monocytes& basophils

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Glucocorticoid-cortisol on anti-inflammatory effects

Stabilizes lysosomal membranes

Stops leukocyte migration & inhibits recruitment of neurophils

Decreases capillary permeability & edema

Inhibition of hypersensitivity & rejection response

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Glucocorticoid-cortisol on eyes & hair/skin

Cataracts & increased IOP

Alopecia & poor wound healing, purport & purple striae

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Cortisol Pharmacokinetics

Hypothalamus (CRH) …anterior pituitary (ACTH)…adrenal cortex (cortisol)

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Cortisol is released

Episodically

Follows sleep-wake cycle

At max just before waking

Lowest 8-10 hrs after waking

Stress-induced release

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Cortisol has

Permissive effects, giving target cell permission to interact w/another “something”

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With cortisol, major surgery will

Increase pro inflammatory cytokines, CRH & ACTH

Cortisol secretion increases 5-10x normal

Normal function may malfunction temporarily after surgery

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Cortisol in moderately invasive surgery

May increase 304x normal

May remain elevated until post day 7

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Cortisol in minor surgery

May double

Often to baseline after surgery

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Primary Adrenal Insufficiency

Localized adrenal gland problem

Autoimmune

Carcinoma

Chronic=Addisnos

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Secondary Adrenal Insufficiency

Pituitary gland not stimulating adrenal glands enough

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What is an adrenal crisis

Fever, syncope, convulsions, hypoglycemia, hyponatremia, severe vomiting & diarrhea

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Addisons disease looks like

Hyperpigmentation Low BP Weakness Wt loss N/V/D Constipation ABD pain Vitiligo

Structural differences or modifications of corticosteroids affect

Glucocorticoid/Mineralocorticoid activity Metabolism

MOA of corticosteroid

Bind cytoplasmic receptors Stimulate/inhibit DNA transcription Regulates protein synthesis

Mineralocorticoid receptors are located in

Renal tubules Colon Salivary glands Hippocampus Cause distal tubular reabsorption of Na & excretion of K+

Glucocorticoid receptors are located

Widely distributed Cause anti-inflammatory & immunosuppressive response

Examples of synthetic glucocorticoids

Prednisolone, Prednisone, methylprednisolone, betamethasoone, dexamethasone & triamcinolone

MOA of synthetic glucocorticoids

Decrease inflammation Prevent activation & migration of immune cells

Betamethasone & Dexamethasone have

No mineralocorticoid activity

Clinical uses of synthetic glucocorticoids

Adrenal insufficiency Allergic reactions Asthma

In adrenal insufficiency, synthetic glucocorticoids...

Cortisol & cortisone replacement Fluid & electrolyte replacement

In allergic reactions, synthetic glucocorticoids have...

Anti-inflammatory effects Delayed therapeutic effects

In asthma, synthetic glucocorticoids are..

Often 1st line regimen Improve lung function & prevent exacerbation Direct inhibition of inflammatory cell mechanisms

With cerebral edema, synthetic glucocorticoids...

Indirectly improve ICP Dexamethasone IV Should be AVOIDED in severe head injury or hemorrhage

With aspiration pneumonitis, synthetic glucocorticoids

Is controversial

With arthritis & lumbar disc disease, synthetic glucocorticoids...

Decrease inflammation & edema Improves symptom flares

Synthetic glucocorticoids are also used for

Ulcerative colitis MG Leukemia Cutaneous disorders Ocular inflammation

Clinical uses of synthetic glucocorticoids in the ICU

Shock Cardiac Arrest Respiratory Distress Syndrome

Adrenal insufficiency contributes to

Vasodilation

In shock, synthetic glucocorticoids increase _____ from endothelial glucocorticoid receptor activation

SVR

In cardiac arrest, synthetic glucocorticoids will

Lower circulating cortisol, vasoplegia & myocardial dysfunction & may improve survival

In respiratory distress syndrome, synthetic glucocorticoids...

Dexamethasone improves outcomes in neonates

Synthetic glucocorticoids use for anesthesia include

Organ transplant (for immunosuppression & decreases risk for rejection Antiemesis (dexamethasone given after induction to prevent PONV; often given w/ondansetron or droperidol Analgesia (peripheral inhibition along cyclooxyrgenase & lipoxygenase pathways; preemptive or intraoperative dexamethasone & betamethasone decreases post pain)

What happens with long term steroid administration, severe adrenal illness & HPA axis suppression?

Reduced cortisol stress response Risk acute adrenal crisis Should continue corticosteroids perioperatively

Symptoms related to synthetic glucocorticoids (anesthesia problems)

Fluid resistant HOTN Changes in consciousness & cognitive decline N/V & Abd pain Hypoglycemia Hyponatremia &hyperkalemia Persistent fever

HPA axis suppression is affected by

Steroid dose & duration

Low-No suppression should be treated by

Prednisone 5mg/day or therapy <3 weeks Glucocorticoid supplementation is not required

If there is assumption of HPA axis suppression, treat with

Prednisone >20mg/day & more than 3 weeks Will have symptoms of Cushing syndrome Glucocorticoid supplementation administered depending on invasiveness of surgery

How to treat unknown HPA axis suppression

5-20mg/day prednisone or prolonged therapy may have variable HPA axis suppression High dose inhaled fluticasone, topical steroids & intra-articular or spinal injections over week-months at high risk of HPA inhibition

How to assess HPA suppression

serum cortisol >10mcg/dl- no inhibition 5-10mcg/dl-some inhibition likely

What are some rationales for stress dose steroids

Permissive effect on vascular tone (enhanced vascular reactivity & inhibition of prostacyclin (PGI2) Catecholamine Levels (cortisol involved in catecholamine synthesis & mediates release from sympathetic neurons Myocardial contractility (improves stroke work index)

Hydrocortisone (Solu-cortef) is used to treat

Acute adrenal crisis 7 Chronic AI 1st line for stress dose steroid replacement Inflammation Status Asthmaticus

Hydrocortisone (Solu-cortef) has what activity?

Glucocorticoid & mineralocorticoid activity

Hydrocortisone (Solu-cortef) is _______acting and lasts_______

Short acting 8-12 hour duration

Hydrocortisone (Solu-cortef) dose for minor surgery

25mg IV

Hydrocortisone (Solu-cortef) dose for moderate surgical stress

50-75mg IV

Hydrocortisone (Solu-cortef) dose for major surgery

100mg

What consideration should you take when a person has normal mineralocorticoid activity and needs replacement therapy

Consider switching to methylprednisolone

Dexamethasone (decadron) is used to treat

Inflammation & allergic conditions Immunosuppression Cerebral edema Shock Antiemesis Analgesia

Dexamethasone (decadron) is a derivative of

Prednisolone

Which medication is a potent glucocorticoid with minimal to no mineralocorticoid activity

Dexamethasone (decadron)

Dexamethasone (decadron) is ______acting, with a a duration of______

Long acting 3-5 days

As an antiemetic, Dexamethasone (decadron) should be dosed at...

4-12 mg IV (dependent on PONV risk)

As an analgesia, what is the dose of Dexamethasone (decadron)

4-10mg for analgesia & prolong duration of regional anesthetic

Dexamethasone (decadron) can be given post-intubation or for positional _______ & should be dosed at_______

Laryngeal edema 10-16mg IV

In neurosurgery, Dexamethasone (decadron) can be given for cerebral edema at what dose?

10mg IV

Adverse effects of corticosteroids

HPA axis suppression (long term tx) Electrolyte & metabolic changes such as hypokalemia, metabolic alkalosis, edema, wt gain, hyperglycemia & fat redistribution Osteoporosis Peptic ulcer disease Skeletal muscle myopathy CNS dysfunction (neuroses, psychoses & cataracts) Lymphocytopenia, increase HCT & inhibition of growth

Larger doses of _____may attenuate cortisol response to surgical stress

Opioids

________can cause minimal suppression of stress-induced endocrine response

Volatile Anesthetics

_______inhibits cortisol synthesis & can cause adrenal insufficiency in critically ill patients

Etomidate

_________can decrease cortisol release & may decrease preoperative complication

Regional Anesthesia