Endocrine/Cancer Flashcards
Common CA surgeries for men
Prostate (#1)
Lung (#2)
Colon/GI
Most common CA surgery for women
Breast
Common sites of metastases for resection
Brain, liver, spinal cord
Considerations for lung CA surgery
1) Potential for massive bleeding during surgery (make sure to type and cross and set up blood warmer)
2) Pulmonary insufficiency after lung tissue resection (will remain intubated after surgery, get a-line to check ABGs)
3) May have associated CAD
Considerations for bronchial and neck CA surgery
1) Look at imaging to determine airway management
2) Ask if they have dysphagia or trouble breathing (checking for airway obstruction)
3) We will lack close accessibility to the airway during the case d/t surgical location
4) Expect significant blood loss
Considerations for those on chemo/radiation
CBC
Check for peripheral neuropathies (chemo can cause these)
Affect of CA and treatment on the heme system
1) Anemia (d/t bone marrow suppression or GI ulceration/bleeding)
2) Neutropenia and thrombocytopenia
Recurrent venous thrombus can occur with ___ CA
pancreatic
Types of lung cancers and their effects on the body
1) Squamous (25-40% incidence)
- hypercalcemia
2) Adenocarcinoma (35-50%)
- hypercoagulability & osteoarthritis
3) Large cell (10%)
- gynecomastia
4) Small cell (15-24%)
- Ectopic corticotropin secretion
- Excess ADH secretion
- Eaton-Lambert Syndrome (similar disease process to MG–> will affect the type of NMB we use)
When may adrenal insufficiency occur?
Adrenal tumor
Corticosteroid therapy
What can happen if TPN is abruptly stopped?
Hypoglycemia
Effects of malignant involvement of the pericardium
1) Pericardial tamponade (often happens as a result of lung CA)
- Electrical alternans (alternation of QRS complex amplitude or axis between beats- the heart essentially wobbles in the fluid filled pericardium)
- Paroxysmal a-fib or a-flutter
Chemo can cause this effect on the heart
Drug induced cardiomyopathy
- LV function may be impaired for up to 3 years post therapy
Invasion of the mediastinum can cause
SVC obstruction
- causes venous engorgement above the waist
Dyspnea and airway obstruction
Chemo meds that are cardiac toxic
Doxorubicin and Daunorubicin
- Causes CHF in <3%
- Acute cardiomyopathy in 10% (benign, and symptoms resolve in 1-2 months)
- SEVERE cardiomyopathy in 2% (mortality rate of 60% in 3 weeks, and unresponsive to mechanical/drug therapy)
- These meds enhance the myocardial depression caused by anesthetics (acute LV failure can occur with GA up to 2 months post treatment)
Chemo meds that are pulm toxic
1) Methotrexate (8% toxicity)
- sudden pulmonary edema (non-cardiogenic)
- progressive inflammation with infiltrates and effusions
2) Bleomycin (dose-related toxicity– rare if below 150mg/m2)
- Pulm endothelial damage (treat with corticosteroids) –> can result in type I and II cell necrosis and pulm fibrosis (no tx)
- Increased A-a gradient
- Hyperoxic pulmonary injury (Do not give 100% O2*****)–> try to keep sats over 90% with less than 30% FiO2
Effects of 5-fluorouracil
Immunosuppression
Leukopenia
Megaloblastic anemia
Chemo meds that are renal toxic
Cisplatin (dose dependent)
- Decreased GFR within 3-5 days
- ATN -> ARF -> hemodialysis
How to treat??
- Hydration and mannitol diuresis (may help to protect against the advancement of renal toxicity)
Chemo meds that cause encephalopathy
1) High-dose cyclophosphamide (acute delerium)
2) Methotrexate (reversible, but can cause dementia with prolonged use)
These meds can cause neuropathies
1) Vinca alkaloids
- peripheral neuropathies
- Autonomic neuropathy (usually reversible)
2) Cisplatin
- dose-dependent damage to the doral root gangia –> large fiber neuropathy
What is autonomic neuropathy?
ANS dysfunction d/t DM
- 20-40% of all diabetics have it
- Most affects the CV and GI systems
Causes:
- Ortho hypotension
- Resting tachycardia
- Impotence
- Peripheral neuropathy
- Loss of HR variability
- Gastroparesis
- Cardiac dysrrhythmia
- Altered breathing regulation
- Sudden death syndrome
These chemo meds can cause plasma cholinesterase inhibition
Alkylating agents (Cytoxan) --it will prolong the effect of sux!!
Bleomycin/Busulfan/BCNU can cause
Interstitial pneumonitis and fibrosis (3-6%)
- appears as cough, dyspnea, and basilar rales
Treatment:
- Corticosteroids
- Avoid high FiO2
- Use colloids rather than crystalloids
Cardiac complications due to doxorubicin/daunorubicin may first appear as
an upper respiratory infection, but with rapidly progress to CHF. Evaluate ventricular function.
Severe cardiomyopathy can occur if 550mg/m2
If a CA patient has N/V, you should always treat them as if they have
a full stomach
These meds are commonly used to treat N/V in the CA population
Reglan
Zofran
Droperidol
Type of pain scale we should use with CA patients
VAS (visual analogue scale)
CA airway evaluation
Tracheal compression or deviation?
Dysphagia or difficulty breathing (airway obstruction)
Trach?
One-lung ventilation?
CA and IV access
Prior mastectomy?
Remember that if on chemo, they may have poor vasculature/access
- Allow adequate time to get enough access
- Pt will often know where their best access sites are
What are we most concerned about with DM?
Making sure they don’t become hypoglycemic**
Type 1 diabetics usually have a fasting BG of
300-500
Type 1 DM will have high ____ and low ___
High glucagon (normally inhibited by insulin) Low insulin
Type 1 DM are prone to these acute events
hypoglycemia and DKA
Fasting BG in type II DM is usually
150-300
Are type 1 diabetics responsive to oral hypoglycemics?
No
Are type II diabetics responsive to insulin therapy?
May or may not be.
DM II is insulin resistant and will have high glucagon levels.
Type II diabetics are prone to this acute condition
Hyperglycemic hyperosmolar nonketotic coma
Why is an in-depth pre-op exam important for diabetic patients?
Because DM affects every system in the body
HgbA1C tests glucose control over the last ___ months
4 months
Glucose stays attached to the Hgb for the life of the RBC (4 months).
Test for diabetic stiff joint syndrome
Prayer sign (patient unable to put palms together) - can indicate difficult airway
Diabetics may have stiffness in these joints that we are concerned about
Atlantooccipital, TMJ, and other cervical joints
__-__% of pts with IDDM have evidence of limited joint mobility, and ___% of IDDM pts will have difficult laryngoscopy
30-40%
30% (d/t AOJ and laryngeal rigidity)
Why should we assess thyroid gland size in DM I pts?
Because they have a 15% incidence having of other autoimmune diseases, like Hashimoto Thyroiditis
Anesthesia things we should be thinking about for pts with DM
Neck mobility?
Do we want the pt to take insulin/hypoglycemic on day of surgery?
How often will be monitor BG?
Do we want IV fluids with glucose?
Need insulin drip?
How tight do we want BG control to be?
How will the pt be managed after surgery?
S/S of DKA
N/V Lethargy Dehydration (look for s/s) Abdominal pain Fruity breath Kussmaul breathing Coma
S/S of Cushing’s Disease (hyperadrenocorticism)
HTN (as it been well controlled??)**
CHF (are they on lasix? watch K levels)
Increased blood volume (salt retention and polycythemia)
Sudden weight gain (usually central)
Moon face (thickening of facial fat)
Glucose intolerance (Diabetes- check glucose level, and control with small amounts of insulin -> 1-5units qh)
Oligomenorrhea or amenorrhea
Decreased libido
Skeletal muscle wasting
Depression or insomnia
Electrolyte abnormalities (hypokalemia, hypernatremia, metabolic acidosis)
S/S of Addison’s disease (hypoadrenocorticism)
Hypotension Hypovolemia Increased BUN and osmolarity d/t hypovolemia Hyperkalemia Hyponatremia Hypoglycemia Muscle weakness Abd/back pain Hyperpigmentation in sun-exposed areas
What is important to BP control in Addison’s disease?
Steroid replacement
Recommended steroid (hydrocortisone) dosing for surgery
Minor surgery
- 25 mg
Major surgery
- 25mg once + 100mg continuous infusion over 24 hours
- 100mg Q8 ( dose pre-op, intra-op, and post-op)
S/S of Conn’s disease (Hyperaldosteronism)
S/S are nonspecific, and many are asymptomatic!! However, is s/s present, they may be
1) HTN d/t sodium and fluid retension
- HA
- DBP 100-125
- May be resistent to treatment**
2) Hypokalemia
- Polyuria, nocturia, muscle cramps and weakness
Pheochromocytoma location
Solitary adrenal (80%) Bilateral adrenal (10%) Extra-adrenal (10%)-- most will be in the abdomen
95% are found in the abdominal cavity
S/S fo pheochromocytoma
MAIN S/S
- HA
- sweating
- Palpitations
Other s/s
- Anxiety
- Tremor
- Pallor
- Chest pain
- Epigastric pain
- Flushing (rare)
- Painless hematuria (rare)
How often to pheochromocytoma episodes occur?
Daily to once every few months
Usually last an hour or less
Meds given for pheochromocytoma
First give an alpha blocker
- Phenoxybenzamine (alpha 1&2)
- Phentolamine (selective alpha 1)
- -> what we will give in the OR as an infusion
THEN give a beta blocker
- Esmolol
____ is the hallmark of primary hyperparathyroidism
Hypercalcemia
Serum Calcium > 5.5mEq/L
iCa > 2.5
Serum Calcium > 7.5 is most likely cancer
Effects of hypercalcemia
Prolonged PR interval****** Shortened QT interval***** HTN***** Muscle weakness Kidney stones Pathologic fractures Somnolescence
Medical management of hypercalcemia
1) Saline infusion if symptomatic (150mL/hr)
2) Loop diuretic (Lasix)
3) Bisphosphonates (IV for life-threatening hypercalcemia– binds to bone and inhibits osteoclasts)
4) Hemodyalisys
5) Mithramycin (inhibits osteoclast activity, but can cause thrombocytopenia, and cause hepatic and renal toxicity)
Diagnosis of hypoparathyroidism
Serum Calcium < 4.5
iCa < 2.0
S/S of hypoparathyroidism
Depends on the rate of onset of hypocalcemia**
Acute (thyroidectomy)
- NM irritability***
- Positive chvostek and trousseau’s sign***
- Airway STRIDOR**
- Restlessness
- Oral parasthesias
Chronic
- Fatigue and muscle cramps
- Prolonged QT
- Lethargy
- Personality changes
What is chvostek’s sign?
Tapping of the facial nerve in front of the ear, causes contraction of muscles of the eye, mouth, or nose
What is trousseau’s sign?
Compression of forearm causes spasm of the hand and wrist
Hypocalcemia causes NM _____
Excitability
Treatment of hypocalcemia
1) Infuse 10mL of 10% Ca gluconate until symptoms of NM irritability dissipate
2) Thiazide diuretics (HCTZ)
- Na depletion with proportional K excretion causes an increased Ca concentration
Lab diagnosis of hyperthyroidism
Elevates T3 and T4
Normal or decreased TSH
Thyroid function test
S/S of hyperthyroidism
Anxiety Weight loss Heat intolerance Exophthalmos Goiter Diarrhea Diaphoresis Tachydysrhythmias Muscle weakness Fatigue
Treatment of hyperthyroidism
1) Beta antagonists (to treat the tachyarrhythmias)
- Propanolol
- Metoprolol
- Atenolol
- Nadolol
2) Antithyroid meds
- Methimazole
- Carbimazole
- Propylthiouracil (PTU)
3) Iodide containing compounds
- Potassium iodide
- Lugol’s solution
- Lithium
- Glucocorticoids
Lab diagnosis of hypothyroidism
Low T3 and T4
Primary disease (increased TSH) Secondary disease (normal or decreased TSH)
Causes of primary hypothyroidism
1) Destruction of thyroid gland
- Chronic thyroiditis (Hashimoto’s)
- Thyroidectomy
- Previous radioiodine therapy
- Irradiation o the neck
2) Deficiency of thyroid hormones
- Anti-thyroid meds
- Excess iodine (inhibits the release of T3&T4)
- Iodine deficiency (inhibits production)
Causes of secondary hypothyroidism
CNS dysfunction
1) Hypothalamic dysfunction (deficiency of thyrotropin releasing hormone)
2) Anterior pituitary dysfunction (deficiency of thyrotropin hormone)
S/S of hypothyroidism
Decreased metabolic activity (by 50%)
Lethargy
Cold intolerance
Cardiac changes (may be earliest clinical manifestation)
Decrease cortisol (d/t atrophy of the adrenal cortex)
Cardiac effects of hypothyroidism
Increased catecholamine circulation Increased SVR HTN Narrow pulse pressure Bradycardia Decreased SV, contractility, and CO CHF may occur occasionally EKG changes (prolonged PR, QRS, and QT) Potential for pericardiac effusion Get an EKG*******
Pulm effects of hypothyroidism
1) Need thyroid hormone to produce surfactant
2) Decreased response to hypoxia and hypercapnia
Renal effects of hypothyroidism
Excessive release of ADH
- causes hyponatremia and inability to excrete free water
Treatment of hypothyroidism
Oral administration of T4
- However, may not be able to tolerate T4 if they have IHD
A positive prayer sign indicates
Cervical immobility and possible difficult intubation
What is our main concern with Cushing’s disease?
HTN- has it been controlled?
Main concern with Addison’s disease
Hypotension
- Need steroid replacement for control!!
