Exam 3 Flashcards
1
Q
Liver accounts for ____% body mass in adults.
A
2%
2
Q
Liver receives _____% CO.
A
25%
3
Q
Liver receives blood flow from:
A
oxygenated blood from hepatic artery
nutrient rick blood from portal vein
each vessel provides 50% of hepatic oxygen supply
4
Q
What controls resistance in hepatic venules?
A
sympathetic innervation from T3-T11
5
Q
In presence of reduced portal venous flow, the hepatic artery can increase flow by as much as ____% to maintain hepatic oxygen delivery.
A
100%
6
Q
what is the reciprocal relationship between flow in 2 afferent vessels?
A
hepatic arterial buffer response
7
Q
portal vein supplies ____% blood oxygen and hepatic artery supplies ______%
A
75% portal vein
25% hepatic artery
8
Q
How many segments of the liver are there?
A
8
9
Q
liver removes ammonia through
A
formation of urea
10
Q
liver is capable of deamination of amino acids, which is required for energy production or conversion of amino acids to carbs or fats. Deamination produces _____.
A
ammonia
11
Q
liver stores important nutrients like:
A
-vitamin A, D, E, K, B12, iron and minterals
-stores glycogen which can be converted to glucose
-in patients with altered liver function, BG concentration can rise several fold higher than postprandial levels found in patients with normal hepatic function
12
Q
What cells in the liver destroy bacteria and remove foreign particles from the blood. It produces immune factors and proteins that combat infections.
A
kupffer cells
13
Q
liver filters about ____ of blood per minute, removing toxins, waste products, bacteria and old RBCs
A
1.4L
14
Q
liver produces bile which is stored in the gallbladder. Bile contains bile salts and phospholipids that emulsify fats and aid in their digestion and absorption.
A
15
Q
all blood clotting facters with exception of what factors are synthesized in the liver
A
3, 4, 8
tissue thromboplastin
calcium
von Willebrand
16
Q
Vitamin K is required for the synthesis of:
A
-prothrombin (factor II)
7
9
10
17
Q
Albumin
A
-most abundant plasma protein made by liver
maintains oncotic pressure
-transports lipids and hormones
antioxidant properties
-serum albumin levels reflect liver function and nutritional status
18
Q
C-reactive protein
A
acute phase reactant produced by liver increases dramatically during inflammation and infection
-activates complement and phagocytosis
19
Q
Ceruloplasmin
A
copper-binding glycoprotein made in liver carries 90% of plasma copper and has ferroxidase activity
20
Q
lipoproteins
A
liver produces VLDL aand HDL which transport lipids through circulation
21
Q
protease inhibitors
A
alpha-1 antitrypsin made by liver protects tissues from proteases like elastase
low levels increase risk of emphysema
22
Q
fibrinogen
A
soluble plasma glycoprotein synthesized by liver and magkaryocytes (bone marrow cells)
-during coagulation, thrombin converts fibrinogen into fibrin forming the fibrin meshwork of a blood clot
10-15% is produced by megakaryocytes which helps maintain adequate fibrinogen level even in severe liver disease
23
Q
Phase 1 liver metabolism
A
-modifies drug with functionalization actions resulting in loss of pharmacologic acitvity
24
Q
Phase II metabolism
A
conjugates the metabolite with a second molecule (glucuronic acid, sulfate, glutathione, amino acid, or acetate) forming a covalent link
25
_______indicated unconjugated bili levels and indicated excess production of bilirubin
unconjugated
26
what is a more sensitive indicator of hepatic disease because of shorter half life of factor 7
PT/INR
27
albumin is______ in chronic liver disesae
decreased
28
Which liver cells have the greatest quantity of cytochrome P450 enzymes and are the site of anaerobic metabolism?
pericentral hepatocytes
29
Which zone is affected most by hypoxia and reactive intermediates from biotransformation?
zone 3
30
Positive pressure ventilation effects on liver blood flow
Mechanical ventilation with positive pressure can impair venous return and CO, reducing perfusion to the liver.
31
effects of drugs used during anesthesia like inhaled anesthetics on liver
vasodilation decreasing hepatic vascular resistance and flood flow
32
What effect does hypotension have on the liver
low blood pressure reduces perfusion pressure to the liver. Causes include hypovolemia, blood loss, effects of anesthetic drugs.
33
Spinal anesthesia effects on liver blood flow
-induces sympathetic blockade and vasodilation, esp if high spinal
-redistributes blood flow to splanchnic vascular bed, helps sustain vascular perfusion
-vascular resistance reduced in hepatic arterial and portal circulation
-vasodilation mediated by decreased vasoconstrictor hormones
34
Anesthetic agents reduce hepatic blood flow by _____after induction.
30-50%
35
which IA increases hepatic blood flow via direct vasodilation properties?
isoflurane
36
treatment of opioid induced spasm of oddi sphincer
Nalbuphine or naloxone
-atropine
-glyco
-glucagon
-nitro
37
in liver disease, Reduced response to endogenous vasocontrictors (AGII, AVP, adn norepi) may be related to what
release of nitric oxide, prostacyclin and other endothelial-derived factors in response to humoral and mechanical stimuli
38
3 major indications for albumin treatment of cirrhotic liver disease:
- after large volume paracentesis
-to prevent renal impairment (bili >4mg/dL or creat >1mg/dL
-presence of HRS-SKI-use in conjunction with splanchnic vasoconstrictors
39
portal hypertension
abnormally high BP in portal vein system, which carries blood from intestines, spleen, pancreas, GB to liver
40
cirrhosis
histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury
41
most common reason for liver transplantation in developing countries is
both HBV and HCV
42
_____has acute symptomology
HAV
43
_____ and _____associated with significant chronic sequelae
HBV and HCV
44
current treatment regimens for liver disease
2 direct acting antiviral drugs that target specific steps within the HCV replication cycle with or without interferon for a duration of 8-12 weeks
45
antiviral drug choice and treatment duration for liver disease are based on:
-genotype of HCV
-stage of liver disease
-presence of cirrhosis
-previous response to interferon
46
_________is most common form in US (70%) and is treated with sofosbuvir/velpatasvir drug combo.
genotype 1A
47
Hyperemesis gravidarum
1st trimester, risk factors:
-hyperthyroidism
-molar pregnancy
-multiple pregnancies
-up to 20-fold elevation of all liver enzymes but not bilirubin
48
HELLP
-most common of later pregnancy liver disease
-microangiopathic hemolytic anemia (MAHA)
elevated liver enzymes
-low PLT count in the preeclamptic patient compromises the HELLP syndrome and occurs in 20% of severely preeclamptic patients up to 25% maternal mortality
49
AFLP
-result of rapid microvesicular fatty infiltration of the liver resulting in acute portal htn and encephalopathy
-association between it and abnormalities in enzymes involved in Beta oxidation of fatty acids
-smytpoms similar to severe preeclampsia and HELLP syndrome but AFLP may have additional clinical findings more unique to liver failure: hypoglycemia, elevated ammonia, asterixis and encephalopathy
50
Normal portal venous pressure
HVPG=1-5mmHg
51
Clinically significant portal HTN (cirrhosis, esophageal varices)
HVPG>10
52
variceal rupture HVPG
>12
53
Key complications of portal HTN include:
1. variceal bleeding-ruptured varices are leading cause of death
2. ascites-fluid accumulating in the abdominal cavity
3. hepatic encephalopathy-confusion, altered mental state
54
cirrhotic leads to have a bleeding diathesis vs DIC which is a thrombotic diasthesis
55
portopulmonary syndrome
pulmonary arterial HTN in setting of hortal HTN with or without liver disease
-systemic vasodilation with local pulmonary production of vasoconstrictor
-mean PAP >25mmHG
-curative tx is liver transplant
56
Hepatopulmonary syndrome
-arterial hypoxemia caused by intrapulmonary vascular dilatations
-triad of portal hypertension, hypoxemia and pulmonary vascular dilatations
-PaO2 <80 mmHg or A:a gradient >15mmHg
-poor tolerance of gravitational effects on pulmonary blood flow leading to platypnea-orthodeoxia: standing worsens hypoxemia, supine improves oxygenation
57
hepatorenal syndrome defined as
acute, reversible kidney failure due to end-stage liver disease
-impaired renal blood flow and intense vasoconstriction
58
causes of hepatorenal syndrome
-splanchnic vasodilation and reduced systemic resistance in liver failure
-decreased effective arterial blood volume
-activation of renin-angiotensin and sns
-intense renal vasoconstriction
59
patho of hepatorenal syndrome
reduced GFR but structurally intact kidneys
-diminished natriuresis, sodium retention, ascites
60
management hepatorenal syndrome
fluid restriction vs intravascular volume depletion, ablumin, avoid nephrotoxins
-vasocontrictors, midodrine, octreotide, norepi
-liver transplantation (without: mortality> 50%)
61
hepatic encephalopathy
-neurotoxins (ammonia) acumulate and alter neurotransmission via glutamate or altered cerebral energy homeostasis
-mild apraxia decerebrate posturing
62
absolute contraindications for TIPS
-heart failure
-severe tricuspid regurgitation
-severe pulmonary hypertension
63
TIPS increases
-venous return which can unmask undiagnosed cardiac dysfunction or pulmonary HTN, two conditions with increased prevalence in patients with CLD
64
Complications of TIPS
-pneumo
-vascular injury
-dysrythmias
hemmorhage
65
MELD score
Model for End-Stage Liver Disease (MELD) is a validated system that UNOS uses for prioritizing patients on a liver transplant waiting list
-uses serum total bili, serum creatinine and INR values to mathematically rank adult patients according to their expected survival rate without transplantation
66
Which meld score is associated with 100% mortality rate?
>/- 40
67
s/s of liver transplantation
-anorexia
-weakness
-n/v/
-abdominal pain
-hepatosplenomegaly
-ascites
-jaundice
-metabolic encephalopathy
spider nevi
-ascites: aspiration of fluid may see big hemodynamic shifts
68
what is the gold standard for hemodynamic monitoring in liver transplantation
PAC
69
intraop managment during liver transplantation
-normovolemia
-coagulopathy: hyper/or hypocoagulable
-temp: keep warm
-limited sensation
-no contraindications to induction agents
-muscle relaxants
-opioid of choice
-post-induction hypotension
-altered pharmacokinetic and pharmacodynamic response
-ICP monitoring
70
wilson disease
an autosomal recessive disease characterized by impaired copper metabolism
71
Alpha-1 antitrypsin deficiency
-genetic disorder that results in defective production of alpha-1 antitrypsin protein
-this protein protects the liver and lungs from enutrophil elastase, an enzyme that can disrupt connective tissue leading to inflammation, cirrhosis and HCC
-in the lungs, patients with alpha-1 antitrypsin deficiency can develop early -onset panlobar emphysema and symptoms of chronic obstructive pulmonary disease
72
hemochromatosis
-disorder associated with excess iron in the body that can lead to multiorgan dysfunction
73
cholecystitis
-caused by obstruction, infection or both
-acute cholecystitis usually related to gallstones 90-95% of the time
-ss include right upper quadrant tenderness, fever and leukocytosis
-inspiratory efforts worsen pain-Murphy Sign
-jaundice-complete obstruction of cytic duct
74
Charcot's triad
-fever/chills
-jaundice
-RUQ pain
75
contraindications to cholecystitis
-coagulopathy
-severe COPD
-ESLD
-CHF
76
insufflation during cholecystitis
-decreased FRC, CC and increased PIP hypotension
-15mmHG routine, higher decreases CO, preload
-increased risk of gastric reflux
77
Achalasia
-impaired relaxation of LES
-chronic achalasia results in dilation of esophagus, more food and fluids retained -aspiration risk
78
Peptic ulcer diseae
-gastric ulcer is loss of mucosa due to inflammation
-approx 98% of peptic ulcer in the stomach and duodenum
-H.pylori infection is associated with development of 90% of duadenal ulcers and roughly 75% gastric ulcers
79
common complications of
-hemorrhage
-perforation
-obstruction
80
gastritis
-inflammatory disorder of gastric mucosa
-stress ulceration, stress erosive gastritis and hemorrhagic gastritis
81
gastric ulcer disease
-develop from degeneration of stomach's mucosal barrier against gastric acid
-pain and anorexia predispose pt to wt loss and metabolic changes
-most common complication is perforation
-most occur in anterior aspect of lesser curvature
82
Gastric neoplastic disease
-gastric cancer 2nd most common cancer worldwide
-7th most in US
-s/s include pain (constant, non-radiating and not relieved by food), wt loss, anorexia, fatigue, and vomiting
-gastrectomy and partial gastrecrtomy remains the primary curative tx
83
mesenteric traction syndrome
-tachycardia and hypotension
-antihistamine and NSAIDS
84
postoperative ileus risk factors
-pain
-anesthesia
-manipulation of bowel contents
-unbalanced electrolytes
-immobility
-intestinal wall swelling from IV fluids
prevention:
start PO feeds ASAP
-early ambulation
minimize bowel manipulation
85
Anastamotic leakage risk factors
-anemias
-co-morbidities
-diabetics
-vascular disease
-decreased perfusion
86
splanchnic blood flow
ANS and the stress response
87
Zollinger-ellison snydrome
-gastroduodenal and intestinal uleration together with gastrin hypersecretion and a non-beta islet cell tumor of the pancreas (gastrinoma)
-gastrin stimulates acid secretion through gastrin receptors on parietal cells and via histamine release
-also excerts a trophic effect on gastric epithelial cells
-gastrinomas can develop in the presence of multiple endocrine neoplasia (MEN) type 1, a disorder involving three primarily 3 organ sites:
-parathyroid glands
-pancreas
-pituitary gland
88
abominal compartment snydrome
-greater than 20mmHG intrabdominal pressure
-normal pressure <10mmHg
-measured with bladder manometer
-organ dysfunction develops if longer than six hours can lead to death
--abdominal trauma, hemoperitoneum, mesentric arterial thrombosis, acute pancreatitis, intestinal obstruction, visceral edema and massive fluid volume replacement
-resuscitative efforts and exposure of the abdomen induce mesenteric edema formation and bowel dilation; delay closure until tension is resolved
89
carcinoid tumors
benign, slow growing
-syptoms related to space occupying
-usually originates in the GIT
-usually asymptomatic
-can be metastatic
-hormones released are metabolized by the liver
-serotonin, histamine, kinin peptides
90
systemic effects of carcinoid syndrome
-flushing
-bronchoconstriction
-hypotension
-HTN
-diarrhea
-life-threatening perioperative hemodynamic instability
91
Treatment of carcinoid syndrome
octreotide
92
carcinoid heart disease
-right sided cardiac involvement
-tricuspid and pulmonary valves
-tumors along valves
-bronchoconstriction
-metastazised by lungs
93
anesthetic plan for carcinoid syndrome
-treat hypoTN with fluids and octreotide, no ephedrine, zofran
94
carcinoid syndrome avoid
-avoid meds that increase release of hormones and mediators from tumor cells
-carcinoid crisis can noecrose and release massive amounts of substances into circulations
-avoid meds that will release hsistamine
95
insulin secretion is enhanced by
-parasympathetic vagal stimulation
-beta adrenergic sympathetic activation
-cholinergic drug administration
96
insulin suppression from
-arterial hypoxemia
-hypothermia
-traumatic stress
-surgical stress
97
alpha adrenergic sympathetic stimulation _____insulin secretion
inhibits
98
beta adrenergic sympathetic and cholinergic blockade also inhibit insulin secretion
99
endocraine functional cells reside in the islets of langerhands
alpha cells secrete glucagon
beta cells secrete insulin
100
acute pancreatitis
causes include:
-alcohol abuse
-trauma
-ulcerative penetration
-infection
-vascular
-metabolic disorders
-autoimmune
-80% pancreatic disorder fromalcohol and gallstones
101
s/s of acute pancreatitis
-abdominal distension
-n/v/
pain
-hypotension
-hypovolemia
102
severe acute pancreatitis
-associated with organ failure, local complications, prolonged ICU and 25% mortality rate
-multiple organ dysfunction main cause of death
-pain radiates from midepigastric to periumbilical can be worse with supine position
103
anesthetic considerations o pancreatic disease
-fluids and electrolytes resuscitation is imperative
-monitor labs: CRP>150mg/L correlates with severity
-ASA standard monitors, large IVs, consider CVP, and A-line
-caution with meds that undergo hepatic biotransformationc
104
chronic pancreatitis
-permanent and irreversible damage to the pancreas
-chronic inflammation, fibrosis, destruction of exocrine and endocrine tissue
-most common etiology is alcohol -70% of cases
105
s/s chronic pancreatitis
abdominal pain
-weight loss
-malnutrition
-hepatic disease
-predisposed to pericardial and pleural effusions
-hypoalbuminemia
-hypomagnesemia
106
pancreatic tumors
pancreatic cancer 80-90% ductal adenocarcinomas
-can grow extensively before they can produce symptoms
-generally resected by pancreaticoduodenectomy (Wipple)
107
pancreatic disease
-painless jaundice
-dull aching midepigastric or back pain
-anorexia
-fatigue
-new-onset DM1 occasionally 1st symptoms
108
diagnostic hallmark-Wipple triad
-hypoglycemia (catecholamine release)
-low blood glucose (40-50mg/do)
-relief after IV administration of glucose
109
what is the most common functioning tumor of the pancreas
insulinoma
-hypoglycemia
-seizures
-coma (syptoms of catecholamine release)
110
Splenic blood flow
300ml/min arises from splenic artery
111
functions of spleen
-blood filtering
-maintenane of normal erythrocytes and immune processing of blood-borne foreign antigens
--abnormal blood cells from disease such as sickle cell disease, thalassemia and spherocytosis removed by macrophages
-can lead to worsening anemia and symptomatic splenomegaly
-pt undergoing splenectomy are at greater risk for post op infection
-spleen not essential for life
112
spleen is the most frequently injured organ
25-60^ of adults intrabd trauma
113
how much CO does spleen receive
5%
114
AST found primarily where
non-hepatic tissues so elevations not specific for hepatic disease
-heart
-skeletal muscle
-kidney
-brain
115
what is the most sensitive laboratory indicator of biliary tract disease
serum GGT
116
what is a sensitive indicator of hepatic disease?
PT/INR because of short 1/2 life of factor 7
117
is serum albumin a reliable indicator of acute liver disease
no, because of 3 week 1/2 life
118
insufflation of CO2 into the peritoneal cavity raises intra-abdominal pressure _______mmHg
12-15
119
Increases In IAO compresses Inferior vena cava, reducing_______ and _______
venous return and decreasing preload
120
Ratio of thyroid hormones
T3:T4=1:10 raitio of secretion
80% deiodination of T4 by body tissues
121
elimination half time T3
24-30 hours
122
elimination half time T4
7 days
123
how much T 3 is free and biologically active
0.3% total T3
124
how much T4 is free and biologically active
0.03% of T4
125
Role of T3 and T4
promote gene transcription and basal cell metabolism
-intestinal absorption of glucose and insulin transport of glucose into cells
-enhance hepatic gluconeogenesis and glycogenolysis
-increase lipid utilization from adipose tissue
-increases the number of Beta-adrenergic receptors and sensitivity to catecholamines-->increases myocardial contractility, decreases SVR, and increases systemic volume
-promote in utero-brain development
-thermogenesis
-heat from body's vital processes
-adaptive thermogenesis
126
Thyroid function is regulated by:
-TSH
-TRH
-T3, T4 and circulating levels of iodine
127
TSH
produced in the pituitary gland and enhances and regulates iodine uptake, T3/T3 production/ secretion by thyroid gland
128
TRH
produced in the hypothalamus and promotes TSH secretion
129
High iodine level effect
down regulate T3/T4 production
130
Calcitonin role
inhibits:
-osteoclast activity
-inhibit renal reabsorption of calcium and phosphorus
131
parathyroid glands
4
-secrete calcitonin in response to high Ca levels which decreases levels of calcium and phosphorus
-negative feedback loop
132
Calcium present in 3 forms
1. 50% protein bound
2. 45% ionized fraction (physiologically active and homeostatically regulated)
3. 5% non-ionized fraction bound with phosphate, bicarbonate and citrate
133
normal calcium level
8.8-10.4mg/dL
134
calcium important for:
-muscle contraction
-coagulation
-NT release
-endocrine secretion
135
for every ____g/dl change in albumin=_____mg/dl change in ca level
1g/dl
0.8g/dl
136
albumin binds ____% protein bound calcium, so albumin levels affect Ca++ levels.
90
137
acidosis and calcium
acidosis:
decreases protein binding of Ca++
-increases ionized ca++ levels in blood
138
alkalosis and calcium
increases protein binding of Ca++
-decreases ionized ca++ levels in blood
139
first sign of hypocalcemic tetany
-laryngeal stridor
-laryngospasm
140
serum thyroxine (T4) levels
evaluated thyroid function
-90% hyperthyroid pt have elevated levels
-85% hypothyroid have low levels
141
serum triiodothyronine
measures T3 levels
-detect disease in patients with clinical s/s of hyerthyroidism
142
Normal range TSH
0.4-4.5
143
radioactive iodine uptake test
measures amount of thyroid uptake of iodine and thyroid activity
-scan after p.o ingestion and measure amount of thyroid activity
144
Graves disease
-most common cause of hyperthyroidism
-autoimmune multinodular (goiter) disease
-thyroid gland hypertrophy
-commonly seen in females (20-40 years)
-due to IgG antibodies attacking the TSH receptor
-commonly seen with Myasthenia Gravis
-exopthalmos (bulging eyes)
145
thyroid adenoma
2nd most common cause of hyperthyroidism
-autonomic functioning thyroid tissue that is not downregulated by increased TSH
146
thyroiditis
hyperthyroidism
-inflammatory process after acite URI with flu like symptoms and treated with NSAIDs
147
Which iodine rich drug can produce thyrotoxicosis (hyperthyroid disease)
amiodarone
148
treatment of hyper thyroidism
antithyroid agents: tapazole (methimazole), PTU-propylthiouracil
-beta-blockers-propanolol (decreases conversion of T4 to T3 but takes up to 2-weeks for this response), metoprolol
-recommended for children and females who are pregnant or breastfeeding
-glucocorticoids (dexamethasone, hydrocortisone) inhibits peripheral conversion of T4 to T3
Surgical resection
-thyroidectomy-large symptomatic goiter or refractory to pharmacologic
thyroid cancer
-obstructive symptoms
149
Anesthetic preop considerations thyroid
primary goal=euthyroid prior to sx
-pharmacologic tx:
-minimum time 10-14 days but up to 8 weeks preop tx
-PTU inhibits conversion of T4 to T3
-methimazole inhibit organification of iodide and blocks T3/T4 synthesis
-beta blockers-decrease SNS activity
-steroids continued through day of surgery, may need stress dose
150
Intra op considerations hyperthyroid
maintain adequate anesthetic depth to block SNS response from surgical stimulation (prevent exaggerated highs/lows in hemodynamics) and avoid the use of SNS -stimulating drugs (ketamine or pancuronium)
Potential complications and risks:
-airway compression or compromise from goiter (continuously evalulaate high airway pressure during surgery)-consider awake fiberoptic intubation with a very large thyroid gland
-cardiac arrhythmias
-potential hyperthermia
-myasthenia gravis incidence increased- initial dose of paralytic should be lowered and TOF twitch monitor required
151
intraop pharm tx
hypotension-use direct acting vasoconstrictors-phenylephrine
tachycardia-esmolol, diltiazam if SVT
152
RLN 1 sided
voice hoarseness (vocal cord paralysis_
153
bilateral RLN injury
vocal cord paralysis -reintubation necessary
-stridor
-aphonia
-respiratory distress from closed vocal cords
154
thyroid storm
acute and life threatening
-acute exacerbation of hyperthyroidism
-most commonly seen in undiagnosed disease or undertreated hyperthyroidism pts because of surgical stress or non-thyroid illness
-can be provoked by surgery on an acutely hyperthyroid gland
-hyperthermia
-tachycardia/dysrhthmias
-myocardial ischemia/CHF
-agitation
-confusion
-HTN
155
Treatment of thyroid storm
=CV and ventilatory support
-immediate cooling
-keep HR <100/min
-high fio2
-stop precipitating factor
-B blockers (esmolol drip or propanolol)
-corticosteroids : hydrocortisone (50-100mg IV Q 6)
-antithyroid meds (PTU)
-sodium iodide 250mg IV Q 6
156
what do you want to avoid in thyroid storm?
salicylates and lasix-both can increase thyroid hormone levels
mortality rate 10-75%
157
Primary hypothyroidism
95% of cases
-decreased production of thyroid hormone despite normal levels of TSH
-surgical section
-iodine (or I-131) or amio tx
-lithium use-blocks thyroid hormone synthesis and release
-hashimoto disease-autimmune thyroid gland destruction
158
secondary hypothyroidism
-cause by hypothalamic or pititary disease
-often associated with other pituitary pathology (post-partum pituitary necrosis, pituitary mass, surgical resection, intracranial radiation therapy)
consider hydrocortisone stress dose esp if they have adrenal insufficiency
159
s/s hypothyroidism
-lethargy
-slow mental functioning
-cold intolerance/hypothermia
-slow movements
-depression
-obesity
-HLD
-reduced metabolic activity
160
if mild to moderate hypothyroid dz is it safe for elective surgery?
yes
161
if severe hypothyroidism
patients neeed to be euthyroid before sx
162
goals for hypothryoid patient:
-respiratory depression
-hypovolemia
-hypoglycemia
-hyponatremia
-hypothermia
163
hypothyroid with CAD
increased risk of MI during euthyroid tx due to increased HR and myocardial O2 demands
164
continue levothyroxine preop has 1/2 life of ____ but needs to be continued in op period
5-7 days
165
hypothyroidism intraoperative tx
-potential difficlt airway if large goter
-exaggerated response to cardio-depressant drugs
-prolonged NMBD relaxation
-hypocarbia
-hyponatremia
-hypoglycemia
-CHF
-refractory hypotension-may have adrenal insuff (steroid dose)
-severe disease invasive monitoring
-keep warm, increase room temp
166
hypothyroid postop care
-recovery may be delayed
-TOF recovery may be delayed
=use quantitative monitoring if available, ensure full muscle recovery/strength before extubation
-ensure normothermic prior to extubation
-toradol (NSAIDS) and peripheral neuraxial anesthesia are preferred for pain control over excess narcotics
-may have prolonged PACU Stage 1 recovery
167
myxedema Coma
medical emergency-severe hypothyroidism
-low MAP
-need for mechanical ventilation
-concurrent sepsis
-only life-saving surgery should be performed
-IV thyroid replacement T4
diagnosed by very low levels of T3/T4
168
myxedema s/s
-impaired LOC/ seizures
-loss of DTRs
-hypoventilation
hypothermia
hyponatremia
-hypoglycemia
-bradycardia
low EKG voltage
non-specific ST/T wave changes
CHF
169
myxedema Tx
-mechanical ventilation
-CV support (inotropes pressors)
IV thyroid hormone replacement
-steroids (tx adrenal insufficiency)
0.9NaCL IVF
-glucose
-gradual correction of both:
hypothermia-too fast can cause CV collapse
hyponatremia-central pontine demyelination
170
primary hyperparathyrodism causes____
hypercalcemia
171
symptoms of hyperparathyroidism (primary)
-nephrolithiasis most common 60-70%
-depression
-confusion
-memory loss
-HTN
-Ekg changes
-heart block with very high Ca levels
172
other causes of primary hyperparathyroidism
-parathyroid ademona (90%)
-hyperplasia (9%)-usually affects all 4 glands
-rarely parathyroid carcinoma
-can exist as part of MEN-multiple endocrine neoplasia
-symtpoms-mainly caused by hypercalcemia
-in pregnancy 50% maternal//fetal mortality-can cause spontaneous abortion
173
primary hyperparathyroidism may result from ectopic production of PTH or analog-like substances from malignancies in:
-lungs
-genitourinary
-breast
GI
-lymphatic system
-tumors can produce hypercalcemia through direct bone reabsorption mechanisms
174
secondary hyperparathyroidism
-increase in parathyroid function that is the result of disease processes that cause:
-hypocalcemia
-decreased vit D metabolism-GI disorders that disrupt absorption
-low Ca_+levels leads to increased PTH secretion
-hyperphosphatemia (ESRD)
-due to decreased renal phosphate excretion
175
Emergency tx for hypercalcemia before surgery
-ca exceeding 15mg/dl
-expand intravascular volume with 0.9 saline IVF
-promote sodium diuresis with lasix promotes Na and Ca excretion
correct hypophosphatemia if prevent
-hemodialysis or peritoneal dialysis when other methods c/i
176
chronic hypercalemia patients need:
EKG /cardiac clearance
-cNS eval
-renal system eval
177
Parathyroidectomy anesthetic management
-GETA commonly used
-TIVA with remi/propofol
-there must be 2nd free back flowing IV for intraop Ca__ and PTH levels, serial draws will typically be 5 apart
-may use NIMS ETT for RLN monitoring-
-sx tx is chosen over any other type of tx modality of hyperparathyroidism because it is curative
178
hypoparathyroidism
-Ca levels <8mg/dl
-most common cause-surgical removal with thyroidectomy
-other causes:neck trauma, malignancy, granulomatous disease
symptoms: neuronal irritability, skeletal muscle spasms, twitching, tetany, seizures
clinical dx: chvostek sign and trousseau
179
treatment of hypoparathyroidism/hypocalcemia
severe symptomatic tx: IV calcium gluconate followed by elemental Ca via IV infusion
180
Calcium gluconate is how much elemental Ca
9% (90mg)
181
Calcium carbonateis how much elemental Ca
40% (500mg)
182
Calcium chloride is how much elemental Ca
27% (270 mg)
183
Calcium citrate is how much elemental Ca
21% (210mg)
184
Adrenal cortex function
to secrete 3 types of hormones:
1. Glucocorticoids (cortisol)
2. mineralocorticoids (aldosterone)
3. androgens
185
Zona glomerulosa
mineralocorticoids=aldosterone and corticosterone
186
zona fasciculata
glucocorticoids--cortisol and cortisone
187
zona reticularis
androgens-estrogen and testosterone
188
what is the most potent glucocorticoid?
cortisol
189
cortisol
-produced in inner portion of adrenal cortex
-has immediate effects on metabolism of carbs, proteins, FA
-responsible for maintenance of immune and circulatory functions
-inactivated by liver and excreted in urine
190
aldosterone
-produced by adrenal gland
-major function is to regulate extracellular fluid volume and potassium homeostasis through the reabsorption of Na+ and secretion of K+ by tissues
191
androgens
responsible for sex organ development and changes that manifest during puberty
192
cushings snydrome
-overproduction of cortisol by adrenal cortex and overdosing of exogenous glucocorticoid therapy
-can also be caused by neoplasm
193
symptoms of cushings
-truncal obestiy
-HTN
-hyperglycemia
-intravascular volume increase
-decreased K
-fatiguability
-abdominal striae
-osteoporosis
-muscle weakness
194
management of cushings
=preop tx of DM, fluid management, HTN and correct electrolyte imbalance
-spirinolactone diuresis-mobilizes excess fluid
-if b/l adrenalectomy is planned the patient will need glucocorticoid replacement tx
195
anesthesia and cushings
-no specific plan but if pt has severe cushings do not use etomidate it will inhibit steroid synthesis (adrenal suppression)
196
mineralocorticoid excess
-too much aldosterone causes HTN, hypokalemic alkalosis, skeletal muscle weakness and fatigue
Anesthetic considerations:
-restore IV fluid volume, electrolyte balance
-HTN and hypokalemia can be controlled by Na intake restriction
197
addisson's disease
-undersecretion of adrenal steroid hormones (decrease of ACTH)
-not apparent until 90% adrenal cortex has been destroyed
-previously due to TB
-now mainly due to autoimmune destruction of the gland
-Hashimoto's thyroiditis is associated with Addisons
-other causes: bacterial, fungal, advanced HIV, sepsis, hemorrhage
s/s: weight loss, n/v,d. chronic fatigue hypotension
198
acute addisions crisis
-abdominal pain
-severe vomiting
-diarrhea
-low BP
-decreased LOC
-shock symtpoms
-severe hyperkalemia
199
management of acute adrenal insufficienc
hydrocortisone 100mg IV bolus followed by hydrocortisone 100mg Q6H for 24 hours
-fluid and electrolyte replacement as indicated by vital signs, serum electrolytes and serum glucose
200
catecholamines are derived from
tyrosine
201
pheochromocytoma arise from
chromaffin cells of adrenal medulla
202
75% of pheochromocytoma are solidary and found where
right adrenal gland
-secrete epinephrine and norepinephrine
203
paragangliomas
extra-adrenal pheochromocytomsa==as
204
s/s pheochromocytoma
-headache
-HTN
-palpitations
-tremors
-sweating
-anxiety
-hyperglycemia
-catecholamine-induced ccardiomyopathy
205
diagnosis of pheochromocytoma
-excess catecholamine or metabolite level
Metanephrine
-normetanephrine
-vanillymandelic acid
206
anesthetic considerations pheochromocytoma
-can masquerade as mh minus increase in etco2
-excision mortality decreased from 50% to 0-3% with preop use of:
-alpha antagonism (must be blocked first):
prevents HTN effects of catecholamines
-started 10-14 days preop along with IVF replacement to mitigate orthostatic hypotension
-long acting irreversible drugs: phenoxybenzamine
-short acting competitive: doxazosin, prazosin, terazosin
beta antagonism-blocked 2nd
-propanolol, atenolol, metoprolol
-should only be started after several days of alpha blockade to avoid unopposed alpha constriction insevere HTN, MI , HF, and other end organ hypertensivefailure
207
post tumor excision of pheochromocytoma
expect precipitous drop in BP (have all pressor agents in line)
208
diabetic fasting glucose levels
>126mg/dL (HBA1C>/6.5%
209
pre-diabetic fasting glucose
100-125mg/dL
HBA1C>/5.7-6.4%
210
type 1 DM
-autoimmune pancreatic B cell destruction causing absolute insuline deficiency and insulin dependence
-hard to maintain blood glucose within normal limits
onset usually <20 years old
risk for DKA and HHNC
=frequently have complications over their life span, retinopathy/blindness, limb infections/amputations, CV disease, neuropathies
211
poorly controlled or long term diabetics
higher risk for heart failure (2-3x higher risk for CAD)
212
autonomic dysfunction and DM
-neuropathy of the autonomic nerves which control vascular tone responses, GI and bladder emptying
-severe bradycardia post-induction and hypotension
-hypothermia
213
insulin day of surgery
-decrease long-acting insulin dose
-skip short acting dose
-ask patient how they manage their insulin especially type 1 DM
-insuline pumps-know how to manage and show how to give insuline dose if necessary during surgery
214
would we prefer a patients glucose level to be low or high during surgery?
=higher sugar better under anesthsia-patient typically used to running with high BG level, low will put the in a stressful state
check glucose hourly if rapidly changing or dose insulin check 30 min
215
hyperosmolar, hyperglycemia non-ketotic coma
BG>600mg/dL
-they are not in ketoaacidosis
-profoudn dehydration (need 1-2 L of NS bolus over 1 hour)
insulin infusion follows above rehydration
-giving insulin infusion before rehydration will cause CV collapse
216
diabetic ketoacidosis
-ketonemia
-hyperglycemia
-acidemia
-bg 250-500mg/dL
-always dehaydrated due to hyperglycemia osmotic diuresis n/v
TX: fluids, insulin, electrolyte replacement
217
Whipple triad
-symptomes of neuroglycopenia (lack of glucose to the brain/CNS symptoms)
-BG <40mg/dL
-relief of symptoms with glucose administration
218
where is the pituitary gland located
-base of brain in sella turcica
219
anterior pituitary (hyposecretion_
-hyposecretion of anterior pituitary tx with hormone replacement therapy and stress doses of corticosteroids
-caused by decrease in ACTH secretion
220
Anterior pituitary (hypersecretion)
-caused by adenoma secondary to cushings secondary to increase in ACTH
-giantism or acromegaly due to excess growth hormone
221
posterior pituitary
secretes vasopressin (ADH)
-oxytocin (uterine contractions and breast milk secretion)
222
diabetes insipidus
-inadequate secretion of ADH or renal tubular resistance to ADH
223
s/s DI
-polydypsia
--hypernatremia
-high output of poorly concentrated urine
-hypovolemia
224
treatment of DI
DDAVP or vasopressin infusion
-isotonic crystalloid
-frequent Na serum level meaasurements
225
causes of DI
destruction of pituitary gland by trauma (head, subarachnoid hemm, brain death) or surgical iinjury
226
siadh causes
-caused bhy excessive ADH production
-head injuries
-intracranial tumors
-pulmonary infections
-lung small cell carcinoma
-hypothyroidism
227
s.s SIADH
-hyponatremia
-very low urine OP
-skeletal muscle weakness
-confusion/seizures
228
treatment of SIADH
-fluid restriction (as low as 800ml/day)
--hypertonic saline infusion (3% NS)
-lasix
229
dont correct serum sodium levels more than:
9meq/L in 24 hours
230
location of kidneys
-behind peritoneum
-right lower than left
-held in place by inferior mesenteric artery
-renal artery enters at hilum
231
bladder pns innervation from
T11-L2
S2-S4 segments
-retropubic space
232
kidneys receive____% CO
25
233
plasma filtration rates:
125-140ml/min
234
2 major determinants of glomerular filtration pressure
1. glomerular capillary pressure
2. glomerular oncotic pressure
235
renal autoregulation of blood flow is controlled by
primarily local feedback signals that regulate glomerular arteriolar tone to protect glomeruli from excessive pressure
236
proximal tubule reabsorbs 2/3rd of NA+ filtrate
ATP drives NA+ into tubular cells and H20 passively follows
237
most common cause of AKI
ATN
tubular necrosis
surgical cause
seen in critically ill patients that have high morbidity rates
-causes high levels of creatine and urea in the blood
-prerenal causes: low MAP and hypoperfusion states
-mortality rate up to 80% : 20-30 min prolonged period of hypotension can precipitate an aKI
238
prerenal azotemia
increased BUN from renal hypoperfusion or ischemia
239
intrinsic acute kidney injury
AKI due to ischemia, nephrotoxins, renal parencyhmal disease
240
post-renal AKI (obstructive)
some type of downstream obstruction tin urinary flow caused by high back pressure into kidney
241
nephrotoxin drugs
-aminoglycosides
-amphotericin B
-cyclosporin A
-ACE inhibitors increase risk of AKI
-loop diuretics linked to postop kidney injury
heavy meatls
-contrast media
nsaids
-antimicrobial and chemo
242
uremic syndrome
extreme form of renal failure in which GFR decreases below 10% of normal
-kidney cant regulate volume and composition of ECF
-excretion of waste products
-pt has low K clearance and need continuous dialysis
-high risk of life-threatening hyperkalemia, metabolic acidosis, CV complications from fluid overload, HTN, autonomic system hyperactivity, electrolyte disturbances
243
anesthetic agents in renal failure
prolonged half life in drugs that are eliminated unchanged:
nmbd
anticholinesterase inhibitors
antibiotics
digoxin
244
which anesthetic agents are ok in renal failure
ketamine
propofol
etomidate
245
s/s of acute hyponatremia in TURP NA 120
CNS changes: confusion restlessness
EKG: possible widening of QRS
246
s/s of acute hyponatremia in TURP NA 115
somnolence
nausea
widened QRS
elevated ST
247
s/s of acute hyponatremia in TURP NA 110
seizures
coma
ventricular tachycardia or fibrillation
248
treatment of Transurethral resection syndrome
-ensure oxygenation and circulatory support
--notify surgeon and terminate procedure asap
-consider insertion of invasive monitors if CV instability occurs
-send blood to lab
-12 lead ECG
-treat mild symptoms > 120 with fluid restriction and loop diuretic
severe <120 with 3% ns at rate of <100ml/hr
d/c 3% when NA >120
249
absolute contraindications to ESQL-shock wave therapy
bleeding disorders/anticoag
pregnancy
250
relative contraindications to ESWL
-large calcified aortic/renal aneurysms
-untreated UTI
-obstruction distal to calculi
-pacemaker, AICD
neurostimulator
morbid obesity
251
