Endocrine Review* Flashcards
Thyroid storm - when TH levels become very high!
One major sign of thyroid storm that differentiates it from hyperthyroidism is ?
marked elevation of body temp (105-106 degrees F)
Management of Thyroid Storm: (4)
- cooled IV crystalloids
- esmolol gtt
- PTU
- potassium iodide
Preoperative Management of Hyperthyroidism/Grave’s Disease:
- AVOID ?
- Administer ?
- Avoid ??
- Anti-cholinergics!!
- anxiolytics, midazolam 2-5 mg
- hypercarbia and hypoxia
Hyperthyroidism-Choice of Induction Drugs:
- Ok = ____
- Good with appropriate dosing = ____
- May see increases in BP with ___
- NO ___!
- TPL
- Propofol
- Etomidate
- Ketamine
Intubation Considerations with Hyperthyroidism:
-With possible difficult airway consider ___
-Non-depolarizers avoid ___ due to possible increase in HR
-PNS - assure complete relaxation to avoid ?
-Lidocaine gooood
Secure tube and tube connections, and PROTECT EYES and NOSE
- Depolarizers (succ 1 mg/kg)
- Pancuronium
- bucking
Preop Management of Hyperthyroidism:
Emergency surgery =
-Give ?
-Thyrotoxicosis
esmolol 100-300 mcg/kg/min
Maintenance of Hyperthyroidism/Grave’s Disease:
- Goal?
- Accelerated Drug Metabolism clinically relevant due to ___
- __ = __ increase in MAC when one degree increase in body temp > ?
- Avoid?
- Treat hypotension-exaggerated response to ___
- ___ = avoid SNS stimulation, prolonged response
- Avoid stimulation of SNS
- increased CO
- Hyperthermia, 5%
- 37 degrees celsius
- local with epi
- direct acting pressors
- Muscle relaxants
Emergence-Hyperthyroidism/Grave’s Disease:
- Thyroidectomy
- Concern with ___
- Damage to adductor fibers of ___ (if bilat = ___, unilat = ___)
- ___ possible, weak rings collapse
- awake BUT NO ___ (xylocaine helpful)
-Vocal cord paralysis
-RLN
obstruction (need to reintubate)
hoarseness (oxygen and assure)
-Tracheomalacia
-bucking
Anesthesia Management-Hypothyroidism:
- Cardiac = ___, decreased (3), increased ___, systemic HTN, narrow pulse pressure, decreased voltage and prolonged PR/QRS/QT interval, potential for ___ and conduction abnormalities
- Respiratory = Decreased response to ___ and ___
- These patients will have a ___ intolerance - peripheral ___ to ___
- Puffy face, macroglossia - issues with airway??
- Bradycardia
- CO, SV, contractility
- SVR
- pericardial effusion
- hypoxia and hypercapnia
- cold intolerance - peripheral vasoconstriction to preserve heat
Preop Management of Hypothyroidism:
- Replacement therapy~postpone surgery?
- ___ = common for adrenal insufficiency
- Caution with ___ (avoid or 1/2 dose)
- fluid replacement
- delayed gastric emptying (Reflux? RSI?)
- Cortisol
- Benzos
Induction-Hypothyroidism:
- Keep warm and need to Avoid ___!
- PreO2 impaired vent. response to decreased O2 and increased CO2
- Meds = ___ good
- ___ low end of dosing
- ___ potential for hypotension esp. in fluid deficit
- prolonged response to ___ go on lower end of dosing
- Sedation
- Ketamine
- Thiopental
- Propofol
- Muscle relaxants
Maintenance of Hypothyroidism: -\_\_\_ alone or with \_\_\_, \_\_\_, \_\_\_ -Keep warm avoid hypothermia -Monitor for early recognition of ??? -Treat hypotension with \_\_\_ Emergence = recovery may be delayed-somnolent, hypothermia will ?
- N2O alone or with low dose benzos
- Opioids
- Ketamine
- Cardiac depression, CHF, hypothermia
- ephedrine 2.5-5 mg IV
- delay MR metabolism
Hyperparathyroidism = ___ is the hallmark of Primary Hyperparathyroidism.
- These patients will thus have ___
- Cardiac = (4)
- GI (___, pain, vomiting, ___) and Renal (polydipsia, polyuria, ___, ___)
- hypercalcemia
- SM weakness
- Prolonged PR, short QT, systemic HTN, anemia
- peptic ulcers, pancreatitis
- stones, decreased GFR
Preop Management of Hyperparathyroidism:
- Manage hypercalcemia for symptomatic hypercalcemia administer?
- Give ?
- Saline infusion 150 mL/hr
- Loop diuretics (lasix)
Anesthetic Management Hyperparathyroidism:
- Patient will be ___ = decrease induction meds, decreased pain sensation, may have personality changes if they do AVOID ?
- Maintain ___, no IV solution with ___.
- Monitor UOP
- Unpredictable responses with ___ due to increased sensitivity and muscle weakness. Need to ??
- somnolent
- Ketamine
- hydration
- Calcium (no LR)
- MRs
- decrease dose and use PNS
Coexisting renal dysfunction with ___ = decreased GFR and stones.
-AVOID ___ and ___!
Hyperparathyroidism
- Sevoflurane
- Enflurane
See Chvostek’s and Trousseau’s Signs with ___!
Acute Hypoparathyroidism
removal with thyroidectomy
Hypoparathyroidism = ___
- Chronic = fatigue and ___, EKG with ___, lethargy, personality changes
- Acute = oral ___, restlessness, NM irritability, + chvostek/trousseau, airway ___
Hypocalcemia
- muscle cramps
- prolonged QT (normal PR, QRS and rhythm)
- paresthesias
- stridor
Preop Management of Hypoparathyroidism:
-Infusion of ___ until symptoms of NM irritability dissipate.
-Give ___ to increase serum calcium concentration
*With induction dose on ___
-Positioning risk for ___ (leak of calcium from bone leads to degeneration)
-AVOID further decreases in calcium - NO ??
Administer ___ IV and correct other electrolytes
- 10 mL of 10% calcium gluconate
- thiazide diuretics (HCTZ)
- low end (lethargic and fatigued)
- osteitis fibrosa cystica
- no massive blood transfusion, no hyperventilation
- CaCl/calcium gluconate 1-4 gm
Anesthetic Considerations NIDDM:
- ___ = can induce hypoglycemia up to ___ after administration.
- Can increase effectiveness of ___.
- ___ metabolized by the liver.
- ___ metabolism is dependent on renal excretion.
- Sulfonylureas
- 50 hours
- Barbs
- Tolbutamide
- Chlorpropamide
30-40% of patients with IDDM show evidence of this, correlates to degree of difficult laryngoscopy due to limited atlanto-occipital mobility and laryngeal rigidity?
Stiff Joint Syndrome
This is secondary to diabetes (affects 20-40% of diabetic patients) - present with orthostatic hypotension, resting tachycardia, impotence, peripheral neuropathy, loss of HR variability, gastroparesis, altered regulation of breathing, cardiac dysrhythmias, sudden death syndrome???
Diabetic Autonomic Neuropathy
Anesthetic Considerations for the Diabetic Patient:
- Avoid ___ agents
- ___ may be appropriate (concern with AN-peripheral neuropathy, hypotension)
- Aggressively treat severe bradycardia with ___ in patients with suspected autonomic neuropathy
- nephrotoxic
- Regional anesthesia
- Epinephrine
Technique for Non-tight Management of the Diabetic: -Fasting BG
- 2nd IV infusion of D5W at ___
- ___ of normal AM intermediate insulin SQ
- 1st IV for fluid replacement as required -Check BS Q ___, adjust D5W
- If BS greater than ___ administer IV regular insulin on sliding scale
- One unit of regular insulin can decrease BS ___ mg/dl
- 100-125 cc/hr
- 30-50%
- 1-2 hours
- greater than 200-250
- 40-50
Tight Glucose Management:
-Fasting BG, start D5W infusion at ___ and maintain throughout surgery
-2nd IV started for normal fluid replacement
-Infusion of ___ of reg insulin in ___ cc NS bag piggybacked-(0.2 u/ml)
~divide hourly BS by ___to get infusion rate
-Check ___ levels frequently and add ___ to each liter of glucose infusate
- 100-150 cc/hr
- 50 units
- 250 cc
- 150
- K+, 20meq
Diabetes - cancel procedure if BS greater than?
-Common meds for NIDDM patients to be on (2)
300
-metformin (glucophage), acarbose
