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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
Q

20 Hydrocortisone/cortisol = ____ Dexamethasone

A

0.75

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26
Q

20 Hydrocortisone/cortisol = ____ Fludrocortisone

A

N/A

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27
Q

When can steroids be d/c’ed?

A

When vasopressor therapy has decreased/no long in need

28
Q

How to d/c steroids

A

< 7 days steroid duration = no taper

> 7d = decrease dose 25% per day

29
Q

What can cause adrenal insufficiency in a single dose?

A

Etomidate

30
Q

Chronic Steroids - suppressed HPA exists

A

Prednisone > 20 mg/daily (or equivalent) for 3w+

31
Q

Chronic Steroids - no suppression of HPA

A

Prednisone < 5mg/daily (or equivalent)

32
Q

Pt taking mg Prednisone daily, vasopressors are increasing, what is tx?

A

Hydrocort 100mg IV q8h

33
Q

Pt taking 4mg Prednisone daily, recovering well from surgery, vasopressors are coming off, tx?

A

Return to 4mg/daily

34
Q

Pt taking 7mg Prednisone daily, recovering well from surgery, vasopressors are coming off, tx?

A

Return to 7mg/daily

35
Q

Pt taking 7mg Prednisone daily, recovering ok from surgery, vasopressors are increasing, tx?

A

May consider Hydrocort 100mg IV q8h (burst steroid dosing)

36
Q

Suggested corticosteroid dose in pt receiving chronic prednisone 5mg/daily - critically ill (sepsis-induced hypotension/shock)

A

Hydrocortisone 50mg IV q6h

Gradual taper following VS

37
Q

Suggested corticosteroid dose in pt receiving chronic prednisone 20mg/daily - Bowel Perforation occurs in OR

A

Hydrocortisone 100 q8

Gradual taper following VS

38
Q

More surgical stress means what in pt receiving chronic steroids at home?

A

More steroids needed periop

39
Q

More baseline steroids taken at home means what in periop setting?

A

More baseline steroids –> patient needs more steroids for procedure than others who do NOT take steroids at home

40
Q

Given a case to taper, what should you pay attention to?

A

Hemodynamic stability, length ( > or < 7days)

41
Q

AE of glucocorticoids

A

Hyperglycemia, leukocytosis, increased risk of infxn

42
Q

Stimulates insulin secretion

A

Hyperglycemia

Beta-adrenergic agonists

43
Q

Pt on long acting insulin - what should be investigated prior to surgery?

A

Last dose given

to avoid hypoglycemia intraop

44
Q

Insulin aspart duration

A

2-4h

45
Q

Insulin Lispro duration

A

2-4h

46
Q

Regular insulin duration

A

6-8h

47
Q

Who should be monitored closely if given insulin?

A

Pt with renal injury

48
Q

Renal failure pt given insulin, what should be monitored?

A

Length of time of insulin will be prolonged – give dextrose if needed

49
Q

insulin requirement in Type 1 DM

A

0.5 - 1 unit/kg/day

50
Q

Side effects of insulin

A
  1. hypoglycemia

2. allergic reaction

51
Q

Insulin resistance

A

daily need for > 100 units of exogenous insulin

52
Q

Metformin should be avoided in

A

Acute Kidney Injury (SCr>1.5mg/dL)

53
Q

Risk in OR w/ patients on Metformin

A

If not d/c’ed 48h prior - risk of lactic acidosis

higher risk if receiving nephrotoxic Rx, IV contrast, low perfusion state

54
Q

Lactic acidosis treatment

A

Supportive care

55
Q

Glyburide

A
  • sulfonylurea
  • DOA 1day
  • Metabolized via liver, + active metabolites
  • Excreted via urine
56
Q

Glipizide

A
  • sulfonylurea
  • DOA .5-1day
  • Metabolized via liver, NO active metabolites
  • Excreted via urine
57
Q

Glimepiride

A
  • sulfonylurea
  • DOA 1+day
  • Metabolized via liver, + active metabolites
  • Excreted via urine
58
Q

Patient with renal injury takes sulfonylurea prior to operation, what to monitor for?

A

Hypoglycemia (esp if + active metabolites - Glyburide, Glimepiride)

59
Q

Target perioperative blood glucose

A

< 180

60
Q

DKA

A

Hyperglycemia (BG > 250)
Ketosis (+urine or serum ketones)
Acidosis (pH < 7.30, serum bicarb <18mmol/L, anion gap > 10)

61
Q

Severe DKA

A

DKA +

  1. severe acidemia pH<7, bicarb <10, anion gap >12
  2. Depressed MS (stupor/coma)
62
Q

Clinical presentation of DKA

A 
Tachycardia
Hypotension
Kussmal Respirations
Hyperkalemia
Polyuria/polydipsia, N/V
63
Q

HHS

A 
Higher BG than DKA (> 600)
- or minimal Ketones
Acidodic (pH >7.30, bicarb >18)
Serum osmolality > 320
Typically Type II
64
Q

Tx of DKA/HHS

A
  1. Fluids
  2. Correction of hyperglycemia (IV insulin at large dose)
  3. Electrolyte (mainly K+) replacement
  4. Correct acidemia
65
Q

What should be monitored while replacing fluids in DKA/HHS?

A

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
Q

primary cause of hypoglycemia in OR

A

liver/renal injury — prolonged insulin clearance

67
Q

Tx of hypoglycemia

A

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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