Endocrine - Co-exisiting

Question 1

Anesthesia Management for HYPERthyroid Pt: Induction

1. Pre-oxygenate- consider? 4. Difficult a/w: MR?
   * Monitor BP/HR/adeq sedation 5. Avoid which NDMR?
2. Good induction meds/ AVOID? * PNS- avoid bucking
3. Intubation: type? tube? * good eye protection
   * xylocaine (IV/LTA):dec SNS stim

Answer 1

1. hypermetabolism - increased O2 demand
2. TPL, propofol, etomidate (may ^ BP) - AVOID Ketamine
3. May need Nasal intubation, RAE tube
4. Succs 1mgkg
5. Avoid pancuronium (^HR)

Question 2

Anesthesia Management for HYPERthyroid Pt: Positioning

1. Thyroidectomy: Positioning/consider?
2. Hyperthermia: MAC considerations?
3. IV access?

Answer 2

1. supine, arms tucked, ulnar nerve injury
2. hyperthermia increases MAC 5%
3. 2 IVs - extension tubing

Question 3

Anesthesia Management for HYPERthyroid Pt: Maintenance

1. Goal?
   * Cooling measures
2. Hypotension: exaggerated response to?

Answer 3

1. Avoid SNS stim

2. direct acting pressors

Question 4

Anesthesia Management for HYPERthyroid Pt: Emergence AND Postop

1. Thyroidecetomy: concern w/? *Postop:
2. Damage to RLN: bilat? unilat? * thyroid storm = emerg
3. Extubation: consider/avoid? * A/w obstruction: RLN
   4. HypoPARAthyroidism

Answer 4

1. VC paralysis
2. bilateral = obstruction, unilateral = hoarseness
3. fully awake, BUT no bucking (xylocaine)
4. hypocalcemia

Question 5

Anesthesia Management for HYPERthyroid Pt: Preop

1. A/w assessment - consider?
2. Pre-meds: good/avoid?
3. Avoid hypercarbia b/c?
4. Avoid hypoxia b/c?

Answer 5

1. goiter (tracheomalacia), voice quality, difficult a/w
2. AVOID anticholinergics, GIVE anxiolytics (versed)
3. stimulates SNS
4. increases metab demands

Question 6

Preop Considerations for HYPOthyroid:

1. A/w? 5. fluid status/glucose
2. temp intolerance? 6. impaired vent response to?
3. increased sensitivity to? * anemia
4. CV and metabolism? 7. cortisol for?
   8. delayed gastric emptying?

Answer 6

1. goiter/difficult a/w
2. cold intolerance/ vasoconstriction
3. depressants - caution with benzos
4. hypodynamic/unresponsive BR and slow metabolism
5. hypovolemia/hypoglycemia
6. hypercarbia and hypoxemia
7. adrenal insuff
8. reflux/RSI

Question 7

Hypothyroidism: RA?

• its an option
  1. Metab of LA?

Answer 7

1. may be delayed = LA toxicity

Question 8

HYPOthyroid: Induction

1. Avoid?
2. Pre-oxygenate well d/t?
3. Induction meds: good/caution?
4. Intubation: considerations/med?
5. MRs: considerations?

Answer 8

1. sedation
2. impaired vent response to hypoxia and hypercarbia
3. Ketamine (good), TPL (low dosing), Propofol (hypotension?)
4. RSI, difficult a/w (goiter), succs
5. prolonged response - use PNS, titrate

Question 9

HYPOthyroid: Maintenance

1. Technique? 3. Hypotension: treatment?
2. MRs? 4. Early recognition of (3?)
   * controlled vent
   * maintain temp

Answer 9

1. N2O alone or w/ low dose benzo’s, opioids and ketamine
2. prolonged response
3. Ephedrine (2.5-5.0)
4. CHF, hypothermia, cardiac depression

Question 10

HYPOthyroid: Emergence

• Recovery may be delayed
  
  • prolonged somnolence
    1. difficult to wean ?
    2. hypothermia causes delayed?

Answer 10

1. vent

2. MR metabolism

Question 11

Anesthesia Management: HYPERparathyroid

• no specific drug requirements 4. Fluids?
  1. somnolence: consideration/meds? 5. MRs: considerations?
  2. intubation: tube? 6. co-existing renal dysfxn:
  3. Positioning? Caution? - dec GFR and stones
  - avoid: VAs?

Answer 11

1. decrease induction meds, decreased pain sensation, personalilty changes (avoid ketamine)
2. armored RAE tube
3. arms at side/demineralization of bones (^ fractures)
4. avoid fluids with Ca2+, monitor UOP
5. increased sensitivity to MRs and muscle weakness - PNS
6. sevo & enflurane

Question 12

Anesthetic Management: HYPOparathyroidism

1. Induction: dosing? 5. Admin Ca2+??
2. Intubation: tube?
3. Positioning/Ca2+ leakage?
4. Avoid further dec in Ca2+?

Answer 12

1. low end dosing - lethargy and fatigue
2. armored RAE tube
3. arms at side/ ostetitis fibrosa cystica
4. massive blood tx and hyperventilation
5. 1-4gm of CaCl and CaGluconate

Question 13

Preop Consideration for Diabetics:

1. type of Dz?
   * meds: insulin vs orals
   * complications: renal dz, HTN, heart dz, autonomic neuropathy, infxn, peripheral neuropathy, gastroparesis
   * labs: EKG, HgbA1C, glucose (goal under 300)

Answer 13

1. IDDM (stiff joint syndrome) or NIDDM

Question 14

Anesthetic Considerations: Diabetes

1. Surgical time? 5. RA = approp- concern with?
2. Intubation: consideration? 6. aggressively treat severe brady w/?
3. AVOID: drugs? - in pts with AN
4. increased sensitivity to?

Answer 14

1. early in the day
2. potential difficult a/w, aspiration precautions, RSI
3. nephrotoxic agents
4. cardio-respiratory depressants
5. autonomic neuropathy, peripheral neuropathy, hypotension
6. epi