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Advanced Health Assessment Unit 2 > Endocrine & Metabolic Disorders Part 1 > Flashcards

Endocrine & Metabolic Disorders Part 1 Flashcards

1
Q

Autoimmune, insulin-dependent, potential association with other autoimmune diseases.
-No production of endogenous insulin, obligatory need for exogenous insulin, disease of childhood/adolescence, DKA risk

A

Type 1 Diabetes

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2
Q

Polygenic & influenced by environment, increasing incidence with higher life span and western cultural habits.
-Cellular insulin resistance and/or impaired insulin release, infrequent DKA, prevalence correlates directly with obesity
-Metabolic Syndrome: HTN, insulin resistance, dyslipidemia, truncal obesity

A

Type 2 Diabetes

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3
Q

Patients initially appear to have DM2, but actually developed antibodies to pancreatitis islet cells & become insulin dependent.

A

Latent Autoimmune DM of adulthood

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4
Q

Relative insufficiency of insulin production & insulin resistance with pregnancy
-Aggressive clinical progress and may persist after pregnany

A

Gestational Diabetes

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5
Q

Due to the side effects of meds, pancreas dysfunction, may also influence ocular and lacrimal function → search for underlying cause!
-Pancreatic surgery, pancreatitis, cystic fibrosis, hemochromatosis

A

Secondary Diabetes

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6
Q

Defects in insulin secretion or action, potential ocular associated malformations

A

Genetic Diabetes

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7
Q

Increased risk of perioperative complications:
-Increased CV morbidity & mortality, CKD, increased risk peripheral nerve injury, wound infections

A

Multi-organ dysfunction complications of Diabetes

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8
Q

Causes Tissue glycosylation, oxidative stress, protein kinase C activation (inflammation), soft-tissue changes & cellular swelling of airway anatomy (potential for difficult airway!!!)

A

Chronic Hyperglycemia

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9
Q

Microvascular: nephropathy, retinopathy, neuropathy
Macrovascular: arterial atherosclerosis
Increased risk of Major Adverse Cardiac Event (MACE)

A

Vascular complications of Diabetes

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10
Q

BP/HR lability/variability → S&S: postural hypotension, resting tachycardia, peripheral sensory neuropathy, lack of respiratory pulse variation
-Increased risk of Myocardial ischemia & cardiopulmonary arrest!!!!
-Delayed gastric emptying → increased aspiration risk!!!

A

Diabetic Autonomic Neuropathy

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11
Q

-Increased risk of peripheral nerve injury (check pressure points), soft-tissue compromise, increased risk of infection
-Poor wound healing, limited wound tensile strength, vascular disease diminishes perfusion to tissues

A

Diabetes Infection/Immune Complications

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12
Q

Has a risk of lactic acidosis (rare), weight loss, favorable w/ lipids, improve resistance to insulin, decreases mortality. Does not cause significant hypoglycemia. Usually hold day of surgery unless renal impairment or use of contrast is expected.

A

Metformin (Biguanides)

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13
Q

Scheduled first case of day, monitor BG, continue all insulin regime until DOS.

A

Diabetic Periop Management

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14
Q

Type 1: receive 1/3-1/2 normal long acting dose
Type 2: nothing - 1/2 long acting dose
Pump: continue basal rate
D/c short acting oral agents on DOS
D/c metformin DOS and do not restart if hepatic or renal failure

A

DOS Diabetic Management

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15
Q

What is the most common cause of periop hyperglycemia?

A

Stress

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16
Q

Target BG 140-180
-Check BG preop and PACU
-Avoid stressful situations (pain, PONV)
-Always r/o hypoglycemia with delayed emergence
-Inc risk of complications: MACE (prothrombotic state, inc plt aggregation/adhesion), pulmonary complications, acute renal injury, altered immune function, poor wound healing, infection.

A

Anesthesia Management of Diabetes

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17
Q

Average glucose level over past 2-3 months, goal <7%, patients w/hyperglycemia but long-term control can proceed to surgery, patients w/ poor control=convo w/ surgeon, postpone surgery if complications (dehydration, DKA, HHS)

A

HgbA1c

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18
Q

Triad: Ketonemia, Hyperglycemia, and Acidemia.
-Insufficient insulin = ketone bodies
-Unable to block lipolysis, so fatty acids are metabolized
-Inc unmeasured anion gap
TX: insulin, fluid, electrolyte replacement

A

Diabetic Ketoacidosis

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19
Q

Ketonemia, BG > 250, Serum bicarb <18, and pH < 7.3

A

Diagnostic criteria for DKA

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20
Q

Hyperglycemia (BG > 600) and profound dehydration (9-12 L).
-Impaired thirst response and mild renal insufficiency
-Hyperosmolarity -> coma, seizures
-Inc plasma viscosity -> intravascular thrombosis
Tx: rehydration, small insulin doses

A

Hyperglycemic Hyperosmolar State (HHS)

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21
Q

Whipple Triad: symptoms of neuroglycopenia (weakness, dizziness, confusion, coma), BG <40, and relief of symptoms with glucose administration.
Tx: Sugar, IV dextrose, glucagon, juice. Goal BG > 100.

A

Hypoglycemia

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22
Q

T4 is 90%
-T4 is converted to T3
-Majority are protein bound
-Unbound (free) hormones are metabolically active
-Has synergistic actions with SNS stimulation (B adrenergic receptors -> Inc contractility and HR)
-Regulated by the Hypothalamic-pituitary-thyroid axis

A

Thyroid Hormones

23
Q

1) Primary: deficiency in endogenous production thyroid hormones
-Hashimoto thyroiditis (autoimmune destruction), destruction from radiation, surgery, Meds: amio, lithium, interferon a & interleukin2
2) Secondary: dysfunction in hypothalamic-pituitary-thyroid axis
-Damage to pituitary gland from radiation/surgery, HTN

A

Hypothyroidism

24
Q

S/Sx:
-slow movements, slow speech, dry sallow skin, myxedema, cold intolerance, anemia, decreased 2,3-DPG (left shift), bradycardia, labile BP, hypoventilation, OSA, fatigue, sleepy, depression, weight gain, constipation, periorbital edema, tracheal deviation, goiter, tracheal deviation, hoarse → airway difficulty

A

Hypothyroidism

25
Q

No recommended screening of asymptomatic patients.
-Normal TSH value rules out primary hypothyroidism
-Primary hypo → high TSH & low T3&T4
-Subclinical hypo → high TSH with normal T3&T4, absence of systemic illness

A

Diagnostic Testing of Hypothyroidism

26
Q

Tx: Levothyroxine: prohormone converted to active T3 (continue perioperatively; half life of 7-10 days). Takes 6+ months to feel better

A

Hypothyroidism

27
Q

Elective: postponed with moderate/severe until euthyroid state achieved, no delay with mild
Urgent: proceed with mild/moderate

A

Hypothyroidism Surgery Implications

28
Q

Severe → chronic clinical symptoms (myxedema coma), AMS, HF, low T4; consult endo
Moderate → overt disease (high TSH, low free T4)
Mild → subclinical disease (elevated TSH, normal T4)
How are you feeling? Any recent changes in your thyroid medicine?

A

Hypothyroidism

29
Q

-Mod/Severe - advanced monitoring (Arterial line, TEE, or PAC)
-Goiter - issues with airway
-Avoid hypo/hyperthermia
-GA/surgery (Stress) can precipitate myxedema coma! Pre-op anxiolysis and multi-modal pain management necessary
-Consider stress dose steroid
-Myocardial depressant activity of anesthetics

A

Anesthesia Considerations for Hypothyroidism

30
Q

More common in women and in countries with iodine deficiency.
-Overactive synthesis/release of T3 and T4 from the thyroid gland

A

Hyperthyroidism

31
Q

Occurs when the thyroid gland has increased metabolic activity
-Graves disease: autoantibodies stimulate TSH receptor
-Toxic multinodular goiter & toxic adenoma

A

True Hyperthyroidism

32
Q

Occurs when metabolic activity of the thyroid gland is decreased.
-Subacute & lymphocytic thyroiditis: inflammation damages thyroid follicular cells & release stored T3 & T4
-Drug-induced (iodine): amiodarone, contrast dyes, lithium, interferon-a, interleukin-2
-Short period of hyperthyroidism, followed by hypothyroid stage, and eventual return to euthyroid state

A

Thyrotoxicosis without Hyperthyroidism

33
Q

Mimic SNS stimulation: hyperkinesis, warm moist skin, carpal tunnel syndrome, tremor, HTN, tachycardia, fatigue, weakness, nervousness, weight loss, inc perspiration, tracheal deviation, exophthalmos, goiter, dysphagia, hoarse (difficult airways!!)

A

Hyperthyroidism

34
Q

No recommended screening in asymptomatic pts.
-Symptomatic: TSH level = most sensitive/specific test; free T4 & total T3 improves diagnostic accuracy
-Primary hyperthyroidism: low TSH, high T3/T4
-Subclinical hyperthyroidism: low TSH, normal T3/T4
-Endocrinology guides testing for new diagnosis: radioactive iodine uptake, ultrasonography, thyroid receptor antibodies

A

Diagnostic Testing for Hyperthyroidism

35
Q

All non emergency procedures are delayed until euthyroid state!
-evaluate fluid/electrolyte status, continue antithyroid & beta blockade DOS! (consider esmolol), AIRWAY!, avoid SNS stimulation (intubation, surgery, extubation), positioning (reverse trendelenburg)
-Hemodynamic monitoring, temperature monitoring
-Consider stress dose steroids, preoperative anxiolysis/pain mgmt
-Remember that anesthetic agents are myocardial depressants.

A

Anesthesia Considerations for Hyperthyroidism

36
Q

Definitive therapy: antithyroid drugs (side effect of hepatotoxicity), radioactive iodine, surgery (thyroidectomy)
-Sympathetic outflow managed with beta blockers
-Pain controlled with NSAIDS & corticosteroids

A

Treatment of Hyperthyroidism

37
Q

1) Regular Insulin, 10 unit IV bolus, followed by an insulin infusion nominally at (BG/150) units/hr
2) Isotonic IV fluids guided by VS and UOP (anticipate 4-10 L deficit)
3) When UOP > 0.5mL/kg/hr, give KCl
4) When BG < 250, add D5W at 100 mL/hr
5) Consider Na bicarb when pH <6.9

A

DKA management

38
Q

Rare in longstanding hypothyroidism, triggered by stressful event
-S/Sx: labile BP, bradycardia, hypoventilation, OSA, hypothermia
-Mgmt: levothyroxine, corticosteroids, supportive measures

A

Myxedema Coma

39
Q

1) Tracheal Intubation and ventilation
2) Levothyroxine 200-300 micrograms IV over 5-10 min, then 100 micrograms IV q 24 hrs
3) Hydrocortisone
4) Fluid and electrolyte therapy
5) Cover to conserve body heat; no warming blankets

A

Management of Myxedema Coma

40
Q

Acute stress in untreated hyperthyroid state, life-threatening!
-S/Sx: HTN, tachycardia, CHF, Afib, MI, hyperthermia
-Mgmt: anti-thyroid meds, supportive measures

A

Thyroid Storm

41
Q

1) IVF
2) Sodium Iodide
3) PTU
4) Hydrocortisone
5) Propanolol or esmolol
6) Cooling blankets, acetaminophen, meperidine (shivering)
7) Digoxin for HF

A

Management of Thyroid Storm

42
Q

Acts to maintain extracellular Ca directly via bone reabsorption and renal reabsorption (phosphaturia and bicarbonaturia; enhanced Ca and Mg reabsorption) and indirectly via effects on Vit. D synthesis
-regulated by serum ionized Ca, phosphate metabolism, & Mg (Mg is required for PTH release)

A

Parathyroid Hormone

43
Q

Works via negative feedback mechanism to maintain normal Ca levels; increases Ca, decreases PO4, decreased Mg = decreased Ca = decreased PTH

A

Parathyroid Hormone

44
Q

Stimulates osteoclasts to release Ca, augments reabsorption of Ca in renal tubules, promotes Vit D formation in the kidneys & Ca absorption from intestine

A

Decreased Calcium (PTH effects)

45
Q

An underproduction of PTH or resistance of end-organ tissue to PTH; results in hypoCa (< 8 mg/dl)
-Most common cause = unintentional removal of parathyroid glands during thyroid/parathyroid surgery (also radiation, neck trauma, malignancy, severe hypoMg bc suppresses PTH secretion, renal insufficiency, VitD insufficiency, pancreatitis, burns)

A

Hypoparathyroidism

46
Q

S/Sx: manifestations of hypocalcemia.
-Neuronal irritability, paresthesias, fatigue, skeletal muscle spasm, tetany, seizures, CHF, hypotension, insensitivity to B agonists secondary to catecholamine release, acute onset after surgery manifest as stridor & apnea!!

A

Hypoparathyroidism

47
Q

Contracture of facial muscle

A

Chvostek Sign

48
Q

Contraction of fingers/wrist (BP cuff)

A

Trousseau Sign

49
Q

Need symptoms under control before surgery.
-Order ECG, Metabolic panel, ionized Ca level
-Correct underlying causes (Ex: if r/t Mg depletion -> give Mg)
-Electrolyte replacement fluid bolus, removal of phosphate from diet, etc.
-Chronic: Ca supplements, VitD analogs
-Acute: IV Ca, monitor Ca levels q2 hrs with clinical S&S, acute severe Ca (<7.5) is a life-threatening emergency!! (laryngospasm & seizures!!)

A

Management of Hypoparathyroidism

50
Q

Autonomous secretion of PTH from solitary or multiple parathyroid adenomas
-Decreased renal excretion of Ca, increased VitD activation → responsible for > 90% of hyperCa in population

A

Primary Hyperparathyroidism

51
Q

Associated with renal failure
-Low serum Ca, elevated PTH, impaired VitD metabolism, VitD deficiency & chronic lithium therapy, most often medically managed

A

Secondary Hyperparathyroidism

52
Q

Occurs after successful renal transplantation
-Autonomous secretion of PTH with hypercalcemia despite normal VitD metabolism (likely require parathyroidectomy)

A

Tertiary Hyperparathyroidism

53
Q

Often asymptomatic: altered LOC, HTN, peptic ulcer dz, renal calculi, polyuria, pathologic fractures (positioning implications)
-Typically order ECG & metabolic panel
-Goal of mgmt: normal Ca levels (<12 is okay), correct hypovolemia (0.9 NS, loop diuretics, biphosphate therapy)
-Ca > 14 requires hospitalization and fluid resuscitation

A

Hyperparathyroidism

Advanced Health Assessment Unit 2 (6 decks)

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