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
Are you going to show the health assessment oral who is boss?
YES
