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Basic Science II > Endocrine (Altose): Adrenals and Pituitary > Flashcards

Endocrine (Altose): Adrenals and Pituitary Flashcards

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1
Q

What are two classes of hormones that the adrenal Cx releases?

Give one example of each (that we went over)

A

Mineralocorticoids (Aldosterone)

Glucocorticoids (Cortisol)

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2
Q

Describe the pathway of Aldosterone release.

A

Renin (kidney) –> Angiotensin I (liver) –> ACE lung –> Angiotensin II

Angiotensin II + serum K –> Aldosterone release (adrenal Cx)

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3
Q

What are the effects of aldosterone?

A

Save Sodium, Pee Potassium

(Na retention, K excretion)

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4
Q

What os Conn’s Syndrome?

A

Hyperaldosteronism due to adenoma

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5
Q

What are some symptoms of hyperaldosteronism?

A

HTN

HypoK metabolic alkalosis

Weakness

Fatigue

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6
Q

How can we treat hyperaldosteronism?

A

Treatment for Conn’s syndrome:

Replace potassium (0.5 mg/kg/hr central line; 4x slower in peripheral IV due to venal irritation)

Sx removal of adenoma

Note: If K > 2.8, cancel non-related elective case! (low serum potassium reflects much larger deficit since K is usally mostly sequestered in cells)

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7
Q

What are some symptoms of hypoaldosteronism?

A

HoTN, Severe hyperK, metabolic acidosis

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8
Q

How can we treat hypoaldosteronism?

A

Administer fludrocortisone

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9
Q

Describe the pathway to cortisol release.

A

CRF (hypothalamus) –> ACTH (ant pituitary) –> Cortisol (adrenal Cx)

CRF: corticotropin releasing factor

ACTH: adrenal corticotropic hormone

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10
Q

According to Dr. Altose, would a year of 5 mg prednisone overpower the body’s ability to make sufficient cortisol for surgical stress?

What is the threshold for stress dose administration with prednisone intake?

A

A year of 5 mg of prednisone should not overpower body’s adrenal gland’s ability to make sufficient cortisol even if taken over a year - this is because body produces 20 mg/day of cortisol normally and can produce up to 300 mg a day under stress.

HOWEVER, 20 mg of prednisone over 5 days can seriously impair the body’s ability to respond to surgical stress for up to 9-12 months (length of time to recover full adrenal cx function)!

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11
Q

What are the effects of cortisol on your body?

A

Increases blood glucose

Catabolic reactions (breakdown)

Anti-inflammatory

Anti-immune

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12
Q

Why does Cushing’s syndrome develop?

A

Develops due to chronic high levels of cortisol due to the intake of oral glucocorticoids/steroids.

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13
Q

What are some signs of Cushing’s syndrome?

A

Truncal obesity

Buffalo hump

Abdominal striae

Hyperglycemia

Osteopenia

HTN

Volume overload

Hypokalemic metabolic alkalosis (hyperaldosteronism)

Immunosuppression

PUD

Emotional changes

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14
Q

What is Addison’s diseases?

A

Disease state of adrenal insufficiency

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15
Q

How should we manage Cushing’s syndrome intraoperatively?

A

Manage HTN

Monitor volume status

Careful with bones

Watch for Addisonian crisis (acute adrenal insufficiency that can occur as a rebound)

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16
Q

What are some primary causes of adrenal insufficiency/Addison’s disease?

A

Idiopathic

Autoimmune

Infection

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17
Q

What are secondary causes of adrenal insufficiency?

A

HPA suppression

HypoACTH

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18
Q

What is our primary intra-op concern with adrenal insufficiency?

A

HoTN

19
Q

How is Addison’s disease diagnosed?

A

Serum cortisol < 18 mcg/dL

Increase of < 9 mcg/dL after admin of 250 mcg ACTH

20
Q

During acute stress, a normal pt’s plasma cortisol should be.. (#)

A

>22 mcg/dL

21
Q

25 mg of cortisol is equivalent to how much hydrocortisone?

Prednisone?

Decadron?

Fludrocortisone?

A

20 mg Hydrocortisone

5 mg Prednisone

0.75 mg Decadron

2 mg Fludrocortisone (use to treat hypoaldosteronism)

22
Q

What is the primary precursor for all catecholamines?

A

Tyrosine

23
Q

What is the rate limiting step in catecholamine production?

A

Tyrosine hydroxylase

Tyrosine –> Tyrosine hydroxylase+Tyrosine –> DOPA

24
Q

What are the roles of COMT and MAO?

A

Enzymes that breakdown catecholamines into metanephrine, nor-metanephrine, and vanillylmandelic acid

25
Q

How is pheochromocytoma traditionally diagnosed?

A

Look for catecholaminergic breakdown products in the urine (metanephrine, normetanephrine, vanillylmandelic acid)

26
Q

What are the symptoms of pheochromocytoma?

A

HTN

Palpitations

Tremor

Sweating

(Similar to MH and Thyroid Storm)

27
Q

How do we pre-operatively manage a pt that has pheochromocytoma?

A

Alpha block first (phentolamine, phenoxybenzamine, prazosin)

Beta block second

28
Q

When managing a pt with pheochromocytoma, why must we give alpha blockers before beta blockers?

A

Beta blockers decrease CO via negative inotropy, etc..

Alpha blocks will drop BP

Drop in BP may be too much for the beta-blocked heart to handle, which may result in heart failure.

This is why we drop BP / alpha block first, so that we can titrate in beta blockers to the point where CO is still maintained.

29
Q

What pressors should we avoid, if we can, in pts with pheochromocytoma?

A

Ephedrine (due to its indirect mechanism of action, it’s difficult to maintain tighter control of Norepi levels)

30
Q

What is the goal of pre-op preparation for a pt with pheochromocytoma?

A

BP management

Volume expansion

This can take ~2 weeks

31
Q

In patients with pheo, what are some intra-op considerations? (monitors, drugs)

A

A-lines

CVP (potential for big boluses and infusions)

Avoid halothane (increases epi, may cause arrhythmias)

Phenylephrine > ephedrine for HoTN

NTG, SNP, nicardipine, Ca-channel blockers for HTN

Avoid histamine release

32
Q

What are post-op complications after removal of an adrenal mass for a pheochromocytoma pt?

A

Rebound HoTN

Renal injury (surgical site close to kidney)

Residual tumor

Rebound hypoglycemia (lots of epi = hyperglycemia)

33
Q

What is the first line treatment for cocaine toxicity?

A

Benzodiazapenes (like Ativan)

34
Q

What structure regulates/stimulates the pituitary gland to release its hormones?

A

Hypothalamus

35
Q

What hormones are released by the anterior pituitary gland? The posterior pituitary gland?

A

Anterior: Prolactin, GH, FSH, LH, TSH, ACTH

Posterior: Vasopressin/ADH, Oxytocin

36
Q

What is the most common reason for patients to undergo a trans-sphenoidal resection of pituitary tumor?

A

Often due to an adenoma

37
Q

What are some common symptoms of pituitary tumors/adenomas?

A

Headaches

Visual problems (pituitary sits on top of optic chiasm)

38
Q

Other than pituitary adenoma, what are some other commonly seen pituitary diseases?

A

Acromegaly (excess release of GH)

DI (diabetes insipidis)

SIADH (syndrome of inappropriate ADH)

39
Q

What is acromegaly caused by?

What are some anesthetic considerations to keep in mind with these patients?

A

Usually caused by excess GH secretion (Growth Hormone)

Usually accompanied by HTN and DM

Anticipate difficult airway

Veins and arteries may be enlarged (do Allen’s test if A-line will be used)

40
Q

What is SIADH characerized by?

What are common causes of SIADH?

A

SIADH is characterized by excess release of ADH. This will lead to hyponatremia due to serum dilution from water retention

Common causes: head injuries, tumors, small cell carcinoma of lungs

41
Q

What causes Diabetes Insipidus? What is it characterized by?

A

DI causes: neurogenic (pituitary stops making it), nephrogenic (ADH stops working in the kidneys)

Characerized by hypernatremia and hypovolemia due to loss of water

42
Q

How would you treat SIADH intra op?

A

Fluid restriction

Lasix

43
Q

How would you treat DI intra op?

A

Replace losses of water

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