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Pharm Fall 2019 > Ex5 Hormones > Flashcards

Ex5 Hormones Flashcards

1
Q

Normal cortisol secretion daily

A

20-30 mg

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2
Q

Peak plasma cortisol secretion occurs when

A

4-8 a.m.

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3
Q

Cortisol is mainly degraded in

A

liver

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4
Q

cortisol is regulated via a ______ by the _____

A 
negative feedback loop
HPA axis (hypothalamic-pituitary-adrenal)
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5
Q

How does stress effect CBG/free cortisol levels?

A

Decreases CBG

Increases free cortisol

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6
Q

How is the HPA effected during illness?

A

Stress + circulating cytokines stimulate hypothalamus –> more cortisol

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7
Q

Cortisol concentrations normalize within _____ postop

A

24hours

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8
Q

Cortisol levels in healthy patient

A

10% biologically active (free cortisol)

90% bound to CBG

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9
Q

CIRCI

A

Cortisol secretion is reduced or tissues are not responsive to cortisol

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10
Q

Adrenal Insufficiency - Lab findings

A

Hyponatremia

Hyperkalemia

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11
Q

Adrenal insufficiency - S/S

A

Hypotension
Tachycardia
Generalized fatigue/weakness

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12
Q

CIRCI - clinical manifestations

A

Hypotension
Unresponsiveness to catecholamine infusion
Ventilator Dependence

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13
Q

Diagnosis of CIRCI

A
  1. ACTH Stimulation test
  2. baseline cortisol
  3. Treat + see result
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14
Q

ACTH Stimulation Test

A
  1. baseline cortisol level
  2. give cosyntropin (synthetic ACTH)
  3. cortisol level 30 min after cosyntropin
  4. cortisol level 60 min after cosyntropin
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15
Q

ACTH stimulation test results

A

Adrenal insufficiency positive if delta = 9 mcg/dL between any level

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16
Q

Disadvantage of ACTH stimulation test

A

All steroids alter results

*except dexamethasone

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17
Q

Cortisol assays measure

A

total cortisol

*NOT free cortisol (the one that produces effects)

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18
Q

Low Level - Random Serum cortisol

A

< 10 mcg/dL

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19
Q

High Level - Random serum cortisol

A

> 34 mcg/dL

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20
Q

Treatment of decreased random serum total cortisol

A

Hydrocortisone 100mg IV q8h

random serum cortisol < 10 mcg/dL

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21
Q

Treatment - > 34 mcg/dL random cortisol

A

do not start glucorticoids

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22
Q

Corticosteroid with no mineralocorticoid potency

A

Dexamethasone

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23
Q

20 Hydrocortisone/cortisol = ____ Prednisone

A

5

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24
Q

20 Hydrocortisone/cortisol = ____methylprednisolone

A

4

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25
20 Hydrocortisone/cortisol = ____ Dexamethasone
0.75
26
20 Hydrocortisone/cortisol = ____ Fludrocortisone
N/A
27
When can steroids be d/c'ed?
When vasopressor therapy has decreased/no long in need
28
How to d/c steroids
< 7 days steroid duration = no taper | > 7d = decrease dose 25% per day
29
What can cause adrenal insufficiency in a single dose?
Etomidate
30
Chronic Steroids - suppressed HPA exists
Prednisone > 20 mg/daily (or equivalent) for 3w+
31
Chronic Steroids - no suppression of HPA
Prednisone < 5mg/daily (or equivalent)
32
Pt taking mg Prednisone daily, vasopressors are increasing, what is tx?
Hydrocort 100mg IV q8h
33
Pt taking 4mg Prednisone daily, recovering well from surgery, vasopressors are coming off, tx?
Return to 4mg/daily
34
Pt taking 7mg Prednisone daily, recovering well from surgery, vasopressors are coming off, tx?
Return to 7mg/daily
35
Pt taking 7mg Prednisone daily, recovering ok from surgery, vasopressors are increasing, tx?
May consider Hydrocort 100mg IV q8h (burst steroid dosing)
36
Suggested corticosteroid dose in pt receiving chronic prednisone 5mg/daily - critically ill (sepsis-induced hypotension/shock)
Hydrocortisone 50mg IV q6h | Gradual taper following VS
37
Suggested corticosteroid dose in pt receiving chronic prednisone 20mg/daily - Bowel Perforation occurs in OR
Hydrocortisone 100 q8 | Gradual taper following VS
38
More surgical stress means what in pt receiving chronic steroids at home?
More steroids needed periop
39
More baseline steroids taken at home means what in periop setting?
More baseline steroids --> patient needs more steroids for procedure than others who do NOT take steroids at home
40
Given a case to taper, what should you pay attention to?
Hemodynamic stability, length ( > or < 7days)
41
AE of glucocorticoids
Hyperglycemia, leukocytosis, increased risk of infxn
42
Stimulates insulin secretion
Hyperglycemia | Beta-adrenergic agonists
43
Pt on long acting insulin - what should be investigated prior to surgery?
Last dose given | to avoid hypoglycemia intraop
44
Insulin aspart duration
2-4h
45
Insulin Lispro duration
2-4h
46
Regular insulin duration
6-8h
47
Who should be monitored closely if given insulin?
Pt with renal injury
48
Renal failure pt given insulin, what should be monitored?
Length of time of insulin will be prolonged -- give dextrose if needed
49
insulin requirement in Type 1 DM
0.5 - 1 unit/kg/day
50
Side effects of insulin
1. hypoglycemia | 2. allergic reaction
51
Insulin resistance
daily need for > 100 units of exogenous insulin
52
Metformin should be avoided in
Acute Kidney Injury (SCr>1.5mg/dL)
53
Risk in OR w/ patients on Metformin
If not d/c'ed 48h prior - risk of lactic acidosis | higher risk if receiving nephrotoxic Rx, IV contrast, low perfusion state
54
Lactic acidosis treatment
Supportive care
55
Glyburide
- sulfonylurea - DOA 1day - Metabolized via liver, + active metabolites - Excreted via urine
56
Glipizide
- sulfonylurea - DOA .5-1day - Metabolized via liver, NO active metabolites - Excreted via urine
57
Glimepiride
- sulfonylurea - DOA 1+day - Metabolized via liver, + active metabolites - Excreted via urine
58
Patient with renal injury takes sulfonylurea prior to operation, what to monitor for?
Hypoglycemia (esp if + active metabolites - Glyburide, Glimepiride)
59
Target perioperative blood glucose
< 180
60
DKA
Hyperglycemia (BG > 250) Ketosis (+urine or serum ketones) Acidosis (pH < 7.30, serum bicarb <18mmol/L, anion gap > 10)
61
Severe DKA
DKA + 1. severe acidemia pH<7, bicarb <10, anion gap >12 2. Depressed MS (stupor/coma)
62
Clinical presentation of DKA
``` Tachycardia Hypotension Kussmal Respirations Hyperkalemia Polyuria/polydipsia, N/V ```
63
HHS
``` Higher BG than DKA (> 600) - or minimal Ketones Acidodic (pH >7.30, bicarb >18) Serum osmolality > 320 Typically Type II ```
64
Tx of DKA/HHS
1. Fluids 2. Correction of hyperglycemia (IV insulin at large dose) 3. Electrolyte (mainly K+) replacement 4. Correct acidemia
65
What should be monitored while replacing fluids in DKA/HHS?
Hypokalemia - realize that insulin will cause serum K+ to decrease. Treat low Potassium before initiating insulin (prevent arrest). AVOID Rx that drops K+ (i.e. lasix, kayexalate)
66
primary cause of hypoglycemia in OR
liver/renal injury --- prolonged insulin clearance
67
Tx of hypoglycemia
IV Dextrose 10-20g, repeat BG in 15 min, additional IV dextrose until BG > 70mg/dL

Pharm Fall 2019 (33 decks)

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