Exam 3: endo pulm disorders/disease Flashcards
body homeostasis is controlled by what two systems
nervous
endocrine
what does the endocrine system work through
mediator hormones
what is the master endocrine gland
pituitary gland
what are 4 body functions the pituitary gland modifies
homeostatic
developmental
metabolic
reproductive
what structure is the pituitary gland located in
sella turcica
what region of the brain is the pitutiary gland connected to
hypothalamus
how does the pituitary gland connect to the hypothalamus
hypophyseal stalk
what controls the secretion of pituitary hormones
hypothalamus
what are the lobes of the pituitary gland
anterior: adenohypophysis
posterior: neurohypophysis
what does AAA mean in pituitary gland
Anterior Adenohypophysis- acromegaly
which hormones come out of anterior lobe of pituitary gland- 6
growth hormone
adrenocorticotropic hormone
thyroid stimulating hormone
follicle stimulating hormone
luteinizing hormone
prolactin
which lobe is 80% of the pituitary gland by weight
anterior lobe-adenohypophysis
after removal of tumor causing hypopituitarism, you worry about your patient developing polyuria. What problem are you worried about and what medication should be available to fix it
diabetes insipidus
vasopressin
what is the approach to the surgery for anterior pituitary tumor
transphenoidal- through the nose to reach gland
what two meds may the patient with hypopituitarism require peri-op during removal of tumor of anterior pituitary gland
steroids
thyroid hormone replacement
t or f- you can nasally intubate patient who will be have a transphenoidal surgical approach
false
what position is patient in for transphenoidal surgical approach
sitting
what two monitors are key during surgery and why for removal of tumor on anterior pituitary using transphenoidal surgical approach in sitting position
precordial doppler
etco2
-detect venous air embolism
what are other important monitors during transphenoidal appraoch for removal of anterior pituitary tumor
BP
HR
what monitor gives the earliest evidence of air embolism during sitting position
precordial doppler
-mill wheel bubble in heart
what gas should not be used during anterior pituitary tumor removal via transphenoidal surgical approach- and why
nitrous oxide- expands spaces, draws in air into cranial spaces= increased ICP
what do you do when surgeon asks for a valsalva maneuver
put vent on manual mode
increase apl pressure to 70
pulse o2 flush to fill bag
squeeze bag- pip will jump up
why would neurosurgeon ask for a valsalva maneuver
surgeon is looking for increased pressure in ICP and leaks in dura. If there are no leaks, he can finish the surgery
why should patient be paralyzed during valsalva maneuver when the high pressure is provided
avoid coughing
the neurosurgeon is about ready to finish his case and asks for a vasalva maneuver. should your patient be paralyzed at this point
paralyzed to avoid coughing
t or f- patient may cough during valsalva maneuver even when deeply sedated
true
what is a drip that could help prevent cough during valsalva maneuver
lidocaine
what is a precaution to take with patient that has head pins or instruments in a sensitive location who will be getting valsalva
paralyze to avoid damage from cough
what volatile gas is neurosafe
isoflurane
what is the preference for patient condition during valsalva maneuver during transphenoidal surgical approach for anterior pituitary tumor removal
- paralyzed
- deep sedation
how many twitches should be present before doing valsalva during transphenoidal surgical approach for anterior pituitary tumor removal
1 or less
during surgery for anterior pituitary tumor removal, what is a consideration with emergence
quick emergence to allow for neuro check
during surgery for anterior pituitary tumor removal, how should emergence be planned for neuro check
-narcotic controlled: not too much so they can wake up
-bp controlled: to make up for htn/tachycardia from pain
t or f-during surgery for anterior pituitary tumor removal, patient should be heavily narcotized at the end of surgery for pain
f-light or no narcotics so patient can perform neuro check on emergence
what is key preop education for patient undergoing surgery for anterior pituitary tumor removal
will wake up with nasal packing
breath through mouth when waking up from surgery/getting extubated
what equipment should be avoided while undergoing surgery for anterior pituitary tumor removal w/ transphenoidal approach
nasal airways- npa or ntt
nasal temp probes
ng tubes
what happens to etco2 during co2 air embolism
drops out
t or f- panhypopituitarism is more common than single decrease in 1 anterior pituitary hormone
true
why does anterior pituitary tumor more commonly cause- hypersecretion or hyposecretion
hypersecretion
anterior pituitary: growth hormone is regulated by ______________________ feedback, where hypothalamus or pituitary hormone synthesis/discharge is stopped
negative
what are the airway considerations for acromegaly
Difficult mask
Difficult DL
Smaller ETT
nothing in nose- large turbinates
why would a DL be more difficult for acromegaly patient
tissue overgrowth
macroglossia
why is a smaller ETT needed for acromegaly patient
vocal cord enlargement
subglottic narrowing
what intubation method should be used for acromegaly patient
rsi with glidescope
-LMA 5 ready as backup
how should acromegaly patient be extubated
awake
what lab should be test pre op for acromegaly patient
glucose
how should patient that is difficult to mask and has sleep apnea be extubated
awake
what hormones does the posterior pituitary secrete
adh/vasopressin
oxytocin
a decrease in plasma volume or blood pressure by what % stimulates adh release
5-10%
what are the two hallmark signs of diabetes inspidius
polyuria
polydipsia
with diabetes insipidus, what med should be given for long term treatment
desmopressin- ddavp
(short term= vasopressin)
is preop vasopressin needed for patient with partial diabetes insipidus and why
no- surgery increases adh release
what meds may be used intraoperatively to treat patient with complete di
desmopressin
vasopressin
when inducing patient with DI, what will likely happen when giving sedative meds and why
hypotension- they will be dry
which disease causes high adh levels causing increased water reabsorption in renal tubules even with hypoosmolarity
SIADH
which portion of pituitary is involved with siadh
posterior
is urine output low or high in siadh
low
_________ can result in water intoxication and hyponatremia leading to brain edema
SIADH
Is sodium high or low in siadh
low- diluted
when should fluid be restricted vs given for siadh
restrict: asymptomatic w/ hyponatremia
hypertonic saline: symptomatic w/ neuro s/s
your diabetic patient has a sudden onset of hypotension. what may be happening
silent MI
what is the goal hbg a1c for dm
<6.5
why is hgb a1c for dm so important
<6.5 prevents long term complications of microvascular diseases
what should be evaluated preoperatively for dm patient
cardiovascular resistance
volume status
ecg
t or f- make sure to positive pressure mask DM patient before rsi
f- no positive pressure masking during RSI
what med should be given preop to dm patients to prevent aspiration
h2 blockers, antacids, gastroprokinetic agents
which patient may have an impaired respiratory response to hypoxia
DM
how do you prevent aspiration in dm patient during preop, intubation, and intraop
preop meds: pepcid, bicitra po
intubate: rsi- roc, succ, intubate
intraop: reglan
what medication helps to speed up gut in dm patient
reglan- helps to speed the gut up and get out of gastraparesis
what is very important to document preoperatively for dm patient
-peripheral neuropathy: sensation, numbness, tingling, parasthesia
-retinopathy
what is a rare occurrence in dm where heart rate does not respond to demand- may not tolerate exercise
autonomic neuropathy
what are s/s of dm patient with gastraparesis
nausea
vomiting
get full quickly-early satiety
bloating
epigastric pain
your patient with dm has stiff joint sydnrome, how do you intubate
videoscope w/rsi
what lab tests should you always check pre op for dm patient- 3
glucose- 80-180 mg/dL= ideal
kidney function- ua, bun, creatinine
electrolytes
a patient with chronic hyperglycemia will likely undergo ________________ _________________ leaving them _______
osmotic diuresis
dry
when should you give insulin pre op for patient with dm- and what kind of insulin
> 180 mg/DL
regular insulin
how do you assess stiff joint syndrome in dm patient
prayers sign
which dm med should be stopped 24-48 hours before surgery
metformin
what are the three times you should test blood glucose for dm patient
preop
intraop
post op
how should dm patient be intubated
videoscope with rsi-
likely have stiff neck
why would ns be used over LR for dm patient
lactate converts to glucose= hyperglycemia
what is the formula for calculating goal blood sugar
starting blood sugar- (0.1 unit/kg x 30)
what would your bolus dose of insulin be for a patient that weighs 187 pounds and has a starting blood glucose of 380 mg/dL and your goal blood sugar is 125 mg/dL
85kg x 0.1= 8.5 units of insulin IV
your patient weighs 176 pounds. Their goal blood sugar is 170 mg/dL and their current bs is 410 mg/DL. How much insulin should be given for a bolus to reach the goal blood sugar
176/2.2= 80kg
80kg x 0.1 units of insulin=
8 UNITS OF REGULAR INSULIN given IV
after giving 8 units of regular insulin as a bolus, how much would you expect blood glucose to decrease
8 units x 30mg/dL= 240 mg/dL
how much will blood glucose decrease if given 1 unit of insulin
30 mg/dL
how do you calculate the regular insulin bolus
weight (kg) x 0.1 unit of regular insulin
for the insulin calculations we do for dm, what is the route of regular insulin
IV
what is the risk for giving metformin on the day of surgery
hypotension
renal hypoperfusion
what lab tests may be elevated in patient taking metformin and therefore should be check preop
kidney function
when should surgery be scheduled for dm patient
morning, as early as possible
how often should blood glucose be checked during intraop
q1 hour
what is the goal of blood glucose control during anesthesia
mildly hyperglycemic
when are post op infection rates higher in patient with dm
prolonged hyperglycemia
what is normal and high normal blood glucose for surgery
normal < 100
high normal 101-125
when should type 2 diabetics stop their oral hypoglycemics
night before surgery- except METFORMIN- STOP 1-2 DAYS BEFORE
what is the biggest risk/cause of hypoglycemia for diabetic patient having surgery
insulin during npo time
how can you treat hypoglycemia for conscious and unconscious patient
1/2 amp of d50= conscious
unconscious= full amp
d50
-check bg q20 mins thereafter
-continuous d5 infusion
at what blood glucose does seizures and loss of conciousness appear
<50 mg/dL
what are some s/s of hypoglycemia
confusion, dizzy, ha, weak, tachycardia, diaphoresis, pupillary dilation, vasoconstriction
t or f- general anesthesia does not prevent the neurologic signs of hypoglycemia
f-it does, that is why you have to check blood glucose frequently
what may happen if hypoglycemia goes untreated
irreversible brain damage
ketoacidosis is more common in which diabetes
type 1
hyperglycemic hyperosmolarity is more common in which diabetes
type 2
which has higher glucose and osmolarity- hhms or dka
HHS
what is the anesthetic plan for conn’s syndrome aka hyperaldosteronism
correct fluid/electrolytes preop
htn= spironolactone
muscle relaxer may be affected by hypokalemia
ekg monitor for hypokalemia
hyperventilation= worsens hypokalemia
in patient with cushing’s, how should you dose muscle relaxants
conservative
what is the anesthetic plan for cushings (high glucocorticoid)
correct fluid/electrolytes preop
thin skin= prone to injury
increased risk of infection
thromboemboli are more common
pheochromocytoma orginates in what gland
adrenal gland
what does pheochromocytoma secrete
norepi alone or w/epi
what symptoms mentioned in preop would alert you to pheochromocytoma- 4
ha
diaphoresis
htn (paroxysmal)
palpitations
what are the non selective alpha antagonists
Phenoxybenzamine
Phentolamine
what are the selective alpha antagonists
prazosin
which should be given first for pheochromocytoma- labetalol or prazosin
prazosin
what lines/monitors are needed for pheochromocytoma
a line
2 large bore iv’s
urinary cath
cvc/pac
when is htn most likely to occur in anesthesia for pheochromocytoma patient- 4
induction
intubation
surgical incision
manipulation
-pre treat!!! w/ prazosin
when is hotn most likely to occur in anesthesia for pheochromocytoma patient
removal of the tumor
what drugs should avoid with pheochromocytoma
droperidol/metoclopramide
histamine releasing drugs
antimuscarinics
desflurane
naloxone
glucagon
phenergan/compazine
what are some histamine releasing drugs to avoid with pheochromocytoma
atracurium
mivacurium
succ
meperidine
MORPHINE
codeine
what are some anti-muscarinics to avoid with pheochromocytoma
atropine, glyco, pancuronium
what nmb can be used for pheochromocytoma that she mentioned
vec
what do you need to be prepared for when pheochromocytoma tumor is removed
hypotension
hypoglycemia
once pheochromocytoma tumor is removed, what bp meds can be used
phenylephrine
epi
what should you ask patient with goiter before surgery
can you lie flat
how do you sleep at night
do you have trouble breathing while supine
what are tsh, t3, t4 in hyperthyroidism
tsh: low
t3/t4: high
what are tsh, t3, t4 in hypothyroidism
tsh: high
t3/t4: low
for patient with hyperthyroidism, what meds should be avoided for sns stimulation- 6
epi
ephedrine
atropine
ketamine
norepi
dopamine
what is A
Liters
what is B
L/Sec
what is C
expiration
what is D
inspiration
what is E
obstructive
what is F
normal
what is G
restrictive
what is H
fixed
what is A (x axis)
volume
what is B
vital capacity
what is C (y axis)
flow
what is D
peak expiratory flow rate
what is E
normal
what is G
obstruction
what is A
Vt
what is B
expiration
what is C
L/sec
what is D
total lung capacity
what is E
residual volume
what is F
functional residual capacity
what is G
vital capacity
What disease is shown and how would you intubate
acromegaly
-rsi with glidescope
what disease is shown here and what med should be given preop to treat it
carcinoid syndrome
-octreotide 24-48 hours before surgery, plus before manipulation of tumor intraop
