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SRNAHealthAssessment > EXAM 3 ENDOCRINE Assessment > Flashcards

EXAM 3 ENDOCRINE Assessment Flashcards

1
Q

Grave’s disease

A

Most common thyroid

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2
Q

Hyperthyroidism may have

A

Thrombocytopenia
Anemia
Hypercalcemia
Exopthltalmos ophtalmopathy

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3
Q

Causes of Thrombocytopenia in hyperthyroidism

A

Autoimmune induced

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4
Q

Causes of ANEMIA in hyperthyroidism

A

altered Fe metab. w/oxidative stress

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5
Q

Causes of ANEMIA in HYPERCALCEMIA

A

Hypercalcemia - altered bone metabolism

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6
Q

All patients undergoing elective procedures should be

A

euthyroid!

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7
Q

Euthyroid Criteria

A

HR <85

No hand tremor

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8
Q

Preoperative Medications for Hyperthyroidism

Goal

A

↓ thyroid hyperfunction, sympathetic stimulation, anxiety, and pain.

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9
Q

Beta blocker for hyperthyroidism preop

A

Consider esmolol gtt to keep HR<90

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10
Q

Use preop for anxiety

A

• Benzos for anxiolysis

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11
Q

Avoid epinephrine with

A

cervical blocks secondary to the ↑ SNS

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12
Q

Avoid anything that could

A

↑ HR/SNS activation (ketamine, ephedrine, atropine)

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13
Q

• Continue all anti-thyroid and Beta-antagonists

A

morning of surgery

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14
Q

Blocks

What if there there is tracheal compression?

A

Superficial or deep cervical plexus block

• If tracheal compression, awake fiberoptic or inhalation induction

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15
Q

Intraoperative Management

A

Adequate anesthesia & pain control

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16
Q

Anticipate with HYPERTHYROIDISM (DCSHE)

A 
- Difficult ventilation/intubation
• Cardiac Arrhythmias
• Sympathetic hyperactivity
• Hyperthermia requiring active cooling
• Excessive airway pressures during manipulations
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17
Q

Interventions for exopthalmos

A

Eye padding for exopthalmos

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18
Q

Avoid adrenergic blockade

A

stimulation or parasympathetic • Slowly titrate meds

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19
Q

HYPERTHYROIDISM: Avoid meds that cause__________– if needed, use

A

HTN or tachycardia ; smaller doses

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20
Q

HYPERTHYROIDISM Avoid (KAIHEP)

A

ketamine, pancuronium, halothane, anticholinergic, epi, indirect vasopressors

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21
Q

Hyperthyroidism treat Hypotension with

A

small doses of phenylephrine

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22
Q

Tachycardia – Esmolol –

A

gives rapid control (requires careful titration & monitoring, but reverses quickly 10 min. vs. Propranolol 4 hrs.)

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23
Q

Hypovolemic and vasodilated –

• Hyperthermia effect on MAC

A 
titrate meds slowly
increases MAC (minimum alveolar concentration)
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24
Q

MAC and temperature relationship

A

• MAC increases 5% for every degree above 37 ° C

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25
Q
  1. Hyperthyroidism and Muscle relaxants dosing?
  2. TTP_____
  3. _______during attack
  4. In hyperthyroidism limit use of muscle relaxants due to ______
A

May need to decrease dose of muscle relaxants
• Thyrotoxic periodic paralysis (TPP) = attack on CNS in presence of hyperthyroidism, hypokalemia during attack
Limit use due to myopathy

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26
Q

Avoid_____, ______ and ______(SNF)

•why?

A

Salicylates, NSAIDS, and furosemide

Interfere with total thyroid hormone levels

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27
Q

Thyroid Storm is a

A

Life-threatening, usually d/t poorly treated hyperthyroidism

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28
Q

In Thyroid storm patient has

A

• Pt.s have marked sensitivity to increased catecholamine secretion or acute emotional/physical stress

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29
Q

***Thyroid storm Most commonly presents_____ post-op with

A

6-18 hrs; high mortality rates

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30
Q

Triggering events for Thyroid Storm (TIS MS)

A
  • trauma
  • infection
  • stroke
  • MI
  • surgery
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31
Q

Nerve Integrity Monitoring (NIM) Tube increase risk of

A

LARYNGEAL NERVE DAMAGE

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32
Q

Thyroid Storm Signs/Symptoms

NAHH-DCT

A 
• Nausea/vomiting
• Anxiety, agitation, delirium
• Hyperthermia
• Hypertension
• Diffuse abdominal pain/obstruction
• CHF/MI or
- Tachycardia, arrhythmias
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33
Q

Thyroid storm The tachycardia/arrhythmia is often

A

resistant to pharmacologic treatment

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34
Q

In Thyroid storm Fever is out of proportion to

A

any evidence of infection

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35
Q

HTN early, then (In thyroid storm)

A

CV collapse

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36
Q

Thyroid Storm Treatment (MSH DIC)

A
  • Maintain CV and Ventilatory support
  • Supplemental O2
  • HR<100 bpm – beta antagonists
  • Decrease temp
  • Ice packs, hypothermic blankets
  • Correct fluid deficits and metabolic abnormalities
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37
Q

Thyroid Storm Treatments

• Don’t take to the OR unless you absolutely have to

A

• Treat cause/triggers
• Invasive monitoring – A-line, central line, PA
Antithyroid meds, iodine, corticosteroids

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38
Q

• Direct removal of thyroid hormones -TS

A

Cholestyramine (Bile-salt sequestrants bind thyroid hormones in the intestine and thereby increase their fecal excretion)
Plasmapheresis
Peritoneal dialysis

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39
Q

MH or Thyroid Storm??

A

dandrolene help both

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40
Q

Hypothyroidism n gastric

A

Treat delayed gastric emptying and adrenal insufficiency

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41
Q

Hypothyroid post op treatment (DENC)

recovery? extubation? muscle strength and temperature.

A
  • Delayed recovery
  • Careful extubation
  • Ensure adequate muscle strength & and normothermic before extubation
  • Nonopioid analgesics or neuraxial blockade preferred
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42
Q

Complications after Thyroid Surgery Trachea

A
  • Tracheal compression

* 2° to tracheomalacia or hematoma

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43
Q

Complications after Thyroid Surgery

A 
Hypoparathyroidism
• Presents with hypocalcemia 24-96 hrs
• Signs: TTCCPHL
• Tetany,
• Chvostek’s sign (nerve twitch)
• Trousseau’s sign (latent tetany)
• Paresthesia
• CHF
• Hypotension
• Laryngospasm
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44
Q

What is myxedema coma
Myxedema Coma Treatment
• ICU –

A 
-Severe Hypothyroidism
mechanical ventilation
cardiac support
fluids
glucose
slow warming
45
Q

Myxedema tx Loading dose of levothyroxine until patient

A

wakes up then maintenance gtt

• initial dose 100 - 500 μg IV followed by 75 - 100 μg daily until pt. is able to take oral replacement.

46
Q

Myxedema coma monitoring include

Steroids?

A
  • Continuous ECG
  • Steroid replacement
  • Ex. Hydrocortisone 100mg q 8h
47
Q

For the Thyroid - Remember:

A

Airway!!
• Consult endocrinology for urgent/emergent surgery if noneuthyroid
• Treatment of hyperthyroid patients / Avoidance of thyroid storm

48
Q

Hyperthyroid patients should take their meds the

A

DOS

49
Q

Hyperthyroid patients may have

A

depleted intravascular volumes

50
Q

Hypothyroid patients CAN MISS A few days of T4 therapy why?

A

long half life

51
Q

Heart: Hypothyroid patients have

A

decreased cardiac output, HR, contractility

52
Q

Ketone formation,

A

anion gap acidosis, dehydration and electrolyte abnormalities

53
Q

• AG calculation formula

A

Na+− (Cl−+ HCO3−)

54
Q

DKA Diagnosis: ph? AG? what about K+

A

arterial pH < 7.30 with anion gap > 12

TOTAL BODY POTASSIUM DEFICIT due to insulin deficiency and Hyperosmolarity, start replacement at 5.3

55
Q

HHNKS (Hyperosmolar, hyperglycemic nonketotic
syndrome)

HHNKS vs DKA

A

Severe hyperglycemia ( >600 mg/dL )
• Profound dehydration
• Hyperosmolarity (350 mOsm/kg; nml 275-295)

NO metabolic acidosis or ketone formation

56
Q

HHNS• PreOperative Tx

A
  • Acquire AM glucose and K+
  • Increased cardiac risk
  • Consider metoclopromide for treatment of gastroparesis
  • Careful mgmt. of preoperative hypoglycemics/insulin
57
Q

HHNS Intraoperative tx

A 
Intraoperative
• Induction: Beware difficult airway, note increased risk of gastroparesis
Maintenance
• careful attention to positioning
• avoid nephrotoxic drugs
• q1h glucose checks (via ABG)
58
Q

Preoperative evaluation of DM

CV

A 
MI (silent?), other MI risks
• Blood pressure
• HR
• Orthostatic hypotension
• Peripheral pulses
• Chest pain/discomfort – where, what
it feels like, what brings it on
**• Check BP in different sites – discrepancies probably mean PVD
***• Orthostatic hypotension – degree of
autonomic dysfunction
59
Q

Preoperative evaluation of DM

Neurologic

A
  • History of stroke
  • Peripheral neuropathy
  • Autonomic dysfunction
60
Q

Preoperative evaluation of DM RENAL

A
  • Renal function
  • Diuretic/dialysis dependence
  • Volume status
  • Skin turgor
  • Mucous membranes
  • Neck veins
61
Q

Preoperative evaluation of DM ENDOCRINE

A
  • Glucose control
  • Hx of DKA or hyperosmolar syndrm.
  • Frequency, severity, & symptoms of hypoglycemic episodes
  • Presence of other endocrine disorders
62
Q

PREOP of DM GI

A

GI
• Delayed gastric emptying
• Gastroparesis
• GERD

63
Q

Preop of HEENT

A

HEENT
• retinopathy
• History of difficult intubation
• Complete airway eval with neck mobility (glycosylation

64
Q

Labs of Preop DM

A

Blood glucose
HgbA1C – less than 7%

Electrolytes
• volume, Osmolarity, acid-base status, creatinine for renal status

ECG

65
Q

Preoperative Considerations DM admission

A

• Preadmit pts w/ hx DKA or ↑ susceptibility to hypoglycemia and Consult primary or endocrinologist

66
Q

DM patients should be

A

First case of the day

67
Q

Pre-, intra-, postoperative

A

blood glucose levels should be determine

68
Q

Type 1 should take a

A 
small amt (1/3 - ½) of their usual morning long-acting
insulin on DOS
69
Q

Type 2 should take

A

none or up to ½ the dose of long-acting or combo of insulins on DOS

70
Q

Preop considerations DM

A

• D/C
All rapid and short-acting insulins
• Short acting oral agents DOS (unless by pump)

71
Q

Patients with pumps should

A

continue only basal rate

72
Q

D/C Sulfonylureas

A

may be d/c’d several days before surgery d/t long half life

73
Q

Metformin: when to stop

A

If renal or hepatic dysfunction then d/c 48 hrs ahea

74
Q

Postoperative Considerations of DM

A
  • Confusion = R/O hypoglycemia
  • Continue any insulin infusions from the OR in the recovery room
  • High risk for poor wound healing, infection, pressure ulcers
75
Q

Pheochromocytoma

A

Tumors that aris from CHROMAFFIN CELLS of the medulla

76
Q

• Goal =

A

prevent effects of catecholamines released by tumor
• HR and BP are essential to monitor
• Calcium channel blockers

77
Q

Alpha blockade in pheochromocytoma

A

Phenoxybenzamine, doxazosin, prazosin, terazosin

78
Q

ALpha first before

A

beta blockers

79
Q

Beta-blockade - dysrhythmias or persistent tachycardia; only after several days of
alpha tx to avoid unopposed alpha constriction (usually 10-14 days)

A

•
• Propranolol, atenolol, metoprolol
• Labetalol – alpha & beta, more beta (1:7)

80
Q

Pheochromocytoma Drugs that block catecholamine synthesis

A

• Alpha-methyl-paratyrosine or metirosine

81
Q

Pheochromocytoma Preop

A

BP <160/90 for more than 24 hrs
• Orthostatic hypotension higher than 80/45 standing
• Absence of ST segment changes andT-wave inversions for 1 week
• Hematocrit decrease of 5%
• Indicates adequate volume expansion
• satisfactory alpha blockade

82
Q

• Less than ____PVC q 5 min (Pheochromocytoma)

A

1

83
Q 
Pheochromocytoma Intraop
BP monitoring
• \_\_\_\_\_\_\_\_ccess or central venous access
• Monitoring for \_\_\_\_\_\_\_\_\_\_
• Minimize \_\_\_\_\_\_\_\_responses – adequate anesthesia
• Treat BP with (4) 
• Tachycardia –\_\_\_\_\_\_\_
• \_\_\_\_\_\_\_agents are preferred as hypotension can ensue following tumor removal
A

BP monitoring
• Large Bore IV Access or central venous access
• Monitoring for ischemia (ECG, TEE prn)
• Minimize catecholamine responses – adequate anesthesia
• Treat BP with nipride, phentolamine, nicardipine, or Mg
• Tachycardia – esmolol
• Short-acting agents are preferred as hypotension can ensue following tumor
removal

84
Q

Pheochromacytoma Postoperative

A

• Hypotension Hypoglycemia
• Rebound hyperinsulinemia d/t insulin release after tumor
excision
• Endogenous insulin secretion is suppressed by increase plasma catecholamines
• Close observation for 24 hrs

85
Q

Cushing’s Perioperative Management

A
  • HTN
  • Blood glucose
  • Normalization of intravascular volume & and electrolytes (Na+)
86
Q

Perioperative Management of Adrenal

Insufficiency

A

• Normal daily corticosteroid dose plus supplemental therapy

87
Q

Perioperative Management of Adrenal
Insufficiency
• Minor procedures:

A

hydrocortisone 25mg or methylprednisolone 5 mg IV on DOS

88
Q

Perioperative Management of Adrenal
Insufficiency
Moderate procedures

A

hydrocortisone 50-75 mg or methylprednisolone 10-15mg IV on DOS then tapered over 1-2 days

89
Q

Perioperative Management of Adrenal
Insufficiency
• Major procedures:

A

hydrocortisone 100-150mg or methylprednisolone 20-30mg on DOS then taper

90
Q

Acromegaly

A

Excess growth hormone

91
Q

With acromegaly expect

A
  • Difficult Airway
  • Distorted face with mandibular expansion
  • Enlarged tongue
  • Enlarged epiglottis
  • Overgrowth of cricoarytenoid joints
  • Vocal cord dysfunction
  • Enlarged nasal turbinates
92
Q

Increase risk of __________ with acromegaly

A

postop resp failure

93
Q

Pituitary Surgery & Preoperative Anesthetic
Considerations
Most common is __________
Obtain _______concentrate on ________

A

• Most commonly transphenoidal approach
• Thorough history and physical – concentrate on hypersecretion
symptoms
• ECG
• Echo if symptoms of cardiac dysfunction
• Cardiac function should be optimized prior to surgery

94
Q

• Labs for pituitary surgery preop

A

include glucose, electrolytes, & hormone levels, type and cross

95
Q

_______should be evaluated

A

• Tumor invasion

96
Q

Pituitary Surgery & Intraoperative Anesthetic
Considerations
•

A
  • Invasive monitoring
  • Aline – BP and labs
  • Central line if major hemodynamic changes
97
Q

Pituitary Surgery & Intraoperative Anesthetic

Considerations

A

Difficult airway equipment
• Intraoperative hypotension
• Inadequate cortisol
• Replacement cortisol, especially if refractory
• Blood loss – usually minimal but can be increased if cavernous sinus entered
• Venous Air embolism – possible but uncommon d/t semi-sitting position

98
Q

Pituitary Surgery & Postoperative Anesthetic
Considerations
Excessive ________ & high plasma ________
• Intra or post-op
• Usually due to reversible trauma to posterior pituitary = insufficient ADH production
• Labs – electrolytes, plasma osmolality
***High plasma osmolality & hypernatremia
• Fluid replacement
**Replace ADH with DDAVP

A

Diabetes Insipidus
• Excessive urine production & high plasma osmolality
• Intra or post-op
• Usually due to reversible trauma to posterior pituitary = insufficient ADH production
• Labs – electrolytes, plasma osmolality
***High plasma osmolality & hypernatremia
• Fluid replacement
**Replace ADH with DDAVP

99
Q

Hypercalcemia
• Hypercalcemia =
__________ may also be seen
• Hypocalcemia = __________

A

ECG – interval changes; signs of dysfunction
• Hypercalcemia = shortened QT interval
Osborn (J waves) may also be seen
• Hypocalcemia = prolonged QT

100
Q

Anesthetic Management of
Hyperparathyroidism
For Surgical parathyroidectomy
Pre-op

A
  • Preoperative
  • Potential cardiac, neurologic, & renal dysfunction
  • ECG, neurologic exam, electrolytes
  • Medical correction of extremely high serum calcium levels
101
Q

Anesthetic Management of
Hyperparathyroidism
• For Surgical parathyroidectomy
• Intraoperative

A

• Careful titration of muscle relaxants – may be more sensitive

102
Q

Anesthetic Management of
Hyperparathyroidism
• For Surgical parathyroidectomy
• Postoperative

A

Serum calcium levels should normalize in 1-3 days

• May see acute hypocalcemia

103
Q

Anesthetic Management of Hyperparathyroidism

• Recurrent laryngeal nerve injury

A

Innervates the intrinsic muscles of the larynx

• Partial injury can affect abductor fibers

104
Q

Anesthetic Management of Hyperparathyroidism

Unilateral recurrent laryngeal nerve palsy

A
  • One vocal cord unable to abduct or adduct

* Hoarseness/stridor

105
Q

Anesthetic Management of Hyperparathyroidism

Bilateral recurrent laryngeal nerve palsy

A
  • Inability to abduct or adduct vocal cords

* May be life threatening & require intubation

106
Q

SLN damage:

A

hoarseness d/t paralysis of cricothyroid muscle, at risk for aspiration (loss of sensation above cords

107
Q

RLN damage:

A
  • Unilateral – hoarseness

* Bilateral – airway obstruction and aphonia

108
Q

T3 is

A

Four times more potent than T4

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