Endocrine Assessment Flashcards
Describe s/s for a hyperthryoid patient.
- Neuro: Anxiety, fatigue
- Optho: Exophthalmos
- Pulmonary/AW: GOITER!!!
- CV: HTN, tachycardia, A fib, high CO
- GI: diarrhea, wt loss
- Renal: hypercalciuria
- MS: muscular weakness
What are some anesthesia implications for a hyperthryoid patient?
- MOST IMPORTANT → make euthyroid before sx
- Eye protection- lubricants
- GOITER → good airway assessment!!
- Difficult intubation?
- Tracheal compression while lying flat?
- Increased neuromuscular blocker sensitivity → prolonged
- Avoid SNS stimulating meds (ketamine, pancuronium, ephedrine, anticholinergics)
- Limit SNS activation → adequate depth of anesthesia
- HR goal < 85 before sx
- Keep cool
What is thyroid storm, possible differentials and treatments?
- Thyroid storm is a complication of hyperthyroid
- life threatening emergency
- response to stress
- hyperpyrexia
- tachycardia
- MI
- Alteration in consciousness
- Differential
- light anesthesia
- pheochromocytome
- neuroleptic malignant syndrome
- malignant hyperthermia
- both have increase HR and heat resposne
- MH would have muscle rigidity and increase ETCO2
- Treatment
- IV fluids
- PTU via NGT
- Sodium iodid
- Hydrocortisone- block converstion T4–> T3 in periphery
- Propranolol/esmolol- block conversion T4–> T3
- Cooling blanket
- acetaminophen
- meperidine
- digoxin
Describe the physical exam findings for a patient with hypothyroidism and anesthesia implications for the patient.
- S/S:
- Neuro: fatigue, depression, memory impairment
- CV: Bradycardia, low voltage EKG, prolonged PR, QRS, QT interval; HTN with narrowed PP
- Respiratory:
- decreased response to hypoxia and hypercarbia
- need thyroid hormone for surfactant production
- GOITER
- LARGE TONGUE
- Optho: blurred vision
- Renal: SIADH- water retention
- Musculoskeletal: hyporeflexia and cold intolerant
- Anesthesia implications: (CEAS)
- Little reason to postpone elective sx with mild/moderate hypothyroidism
- Severe hypothyroidism→ postpone sx
- Maintain meds up to morning of sx
- CV changes are often the earliest changes
- Cortisol deficiency possible- atrophy of gland
- Sensitive to sedatives
- Large tongue lead to difficult airway
- Goiter may compress airway
What is a myxdema coma, s/s and treatment?
- Extreme hypothyroidism
- medical emergency 25-50% mortality
- may be precipitated by sx, trauma, or infection
- S/S
- coma
- hypoventilation
- hyponatremia (SIADH)
- CHF
- Bradycardia
- Treatment
- trahceal intubation and controlled vnetilation
- levothyroxine 200-300 mg IV
- Hydrocortison 100 mg IV
- keep warm
- repalce electolytes as needed
Describe s/s hyperparathyroidism? What are some anesthesia impliacations?
S/S:
- Neuro: mental status change- delirium, psychosis coma
- CV
- HTN
- EKG changes (prolonged PR, short QT, wide T waves)
- arrhythmia
- GI
- n/v
- constipation
- pancreatitis
- Renal
- stones,
- polyuria
- polydipsia
- impaired renal concentrating ability
- dehydration
- MS
- Weakness
- osteoporosis
Dx:
- increased Ca> 10.4 mg/dL
- Increased PTH
- Incresed 1,25 Vit D
- Decreased phosphate
Anesthesia implications:
- Low threshold to get EKG
- No evidence that a specific anesthetic drug/technique has any advantage over other
- scheduled: no speical monitors required
- emergency: aline, central line, foley
- frequent labs, electoylte imbalance, UO
- Unpredictable response to NMB–> may require decreased dosing and frequent monitoring
- careful positioning
Describe the s/s for a patient with hypoparathyroidism. and some anesthesia implications for care of the patient.
S/S
- Neuro: psychosis, anxiety, depression
- CV: hypotension, EKG changes (prolonged QT), CHF
- Resp: laryngospasms and apnea
- NM:
- Tetany
- Chvostek’s → tap facial nerve (anterior to ear) → twitching of lip/spasm
- Trousseau’s → BP cuff inflated for 3 minutes → carpal spasm of hand
- Paresthesias
- Tetany
Anesthesia implications:
- Low threshold to get EKG
- No evidence of speicfic anesthetic drug/technique over the other
- correct Ca and Mg
- Treatment for Ca:
- symptomatic
- Calcium gluconate 10-20 mL 10% solution
- or calcium chlroide 10 mL 10% <<— caustic to veins
- IV Mg 2-4 mg IV
- Calcium gluconate 10-20 mL 10% solution
- asymptomatic
- oral Ca and Vit D supplement
- symptomatic
- Treatment for Ca:
- Judicious use of albumin or large amounts of blood
- will bind and decrease Ca levels even further
- Avoid respiratory alkalosis- decreases ionized ca, and already have low Ca level
What oral anti-diabetic medications would you hold preoperatively and why?
- Meglitinide (Repaglinide)
- MOA- increase insulin release (ATP dependent K ATPase pump)
- Hold 24 hours d/t r/f hypoglycemia
- Sulfonylureas (Glyburide)
- MOA- increase insulin release (ATP dependent K ATPase pump)
- Hold 24 hours d/t r/f hypoglycemia
- Biguanide (Metformin)
- MOA- decrease gluconeogenesis
- Hold 24 hours- d/t r/f lactic acidosis
What are some end organ dysfunctions that you should evaluate for in the preop assessment of a diabetic patient?
- Atherosclerosis- CAD; PVD; CVD; HTN;CMP & silent MI
- Diabetic nephropathy (20-40%)- microalbuminuria, proteinuria, chronic renal failure
- Neuropathies
- Stroke
- Polyneuropathy
- Autonomic neuropathy
- GI (gastroparesis)
- MS- stiff- joint syndrome;
- Other: infection
What are some s/s of autonomic dysfunction for a diabetic patient?
- CV (most seen)
- Loss of beat to beat variability
- Tachycardia @ rest
- Orthostatic hypotension (lightheaded/dizzy)
- Exercise intolerance (HR too high)
- Silent MI
- GI:
- Esophageal dysmotility
- Gastroparesis
- constipation/diarrhea/incontinence
- GU:
- Neurogenic bladder
- Erectile dysfunction
- Misc:
- Dry skin
- Anhidrosis
What are some complications of autonomic dysfunction in a diabetic patient?
- Intraoperative hypotension
- Increased vasopressor support
- Increased response to intubation
- Perioperative arrest
- Intraoperative hypothermia
What are some tests you might order for someone with DM?
- CV
- EKG
- Stress test, ECHO
- May display old infarcts- Q waves (silent MI)
- Labs
- A1C >9% (poor control)
- Electolytes
- UA
- CBC
- BG before surgery
What are S/S of someone with DKA? (Hint: Think patient presentation NOT lab values).
Acute abdominal pain
Lethargy
Hypovolemia
Kussmaul breathing
Polydipsia
Polyuria
What are some airway assessment findings for a patient with severe diabetes?
- Limited atlanto-occipital joint mobility
- Limited temporomandibular joint mobility
- Limited cervical spine mobility
- Positive prayer sign
- Palm print sign (grade 0-3)
- → stiff joint syndrome
Risk factors for hypoglycemia.
(PLAID)
Pregnancy
Liver/renal disease
Adrenal insufficiency
Infection
Decreased oral intake
What can cause unawareness of hypoglycemia?
(BALDS)
Beta blockers
Advanced age
Long term DM
Diabetic neuropathy
Sedation
Are you going to show the health assessment oral who is boss?
YES
