EXAM 3 ENDOCRINE Assessment Flashcards
Grave’s disease
Most common thyroid
Hyperthyroidism may have
Thrombocytopenia
Anemia
Hypercalcemia
Exopthltalmos ophtalmopathy
Causes of Thrombocytopenia in hyperthyroidism
Autoimmune induced
Causes of ANEMIA in hyperthyroidism
altered Fe metab. w/oxidative stress
Causes of ANEMIA in HYPERCALCEMIA
Hypercalcemia - altered bone metabolism
All patients undergoing elective procedures should be
euthyroid!
Euthyroid Criteria
HR <85
No hand tremor
Preoperative Medications for Hyperthyroidism
Goal
↓ thyroid hyperfunction, sympathetic stimulation, anxiety, and pain.
Beta blocker for hyperthyroidism preop
Consider esmolol gtt to keep HR<90
Use preop for anxiety
• Benzos for anxiolysis
Avoid epinephrine with
cervical blocks secondary to the ↑ SNS
Avoid anything that could
↑ HR/SNS activation (ketamine, ephedrine, atropine)
• Continue all anti-thyroid and Beta-antagonists
morning of surgery
Blocks
What if there there is tracheal compression?
Superficial or deep cervical plexus block
• If tracheal compression, awake fiberoptic or inhalation induction
Intraoperative Management
Adequate anesthesia & pain control
Anticipate with HYPERTHYROIDISM (DCSHE)
- Difficult ventilation/intubation • Cardiac Arrhythmias • Sympathetic hyperactivity • Hyperthermia requiring active cooling • Excessive airway pressures during manipulations
Interventions for exopthalmos
Eye padding for exopthalmos
Avoid adrenergic blockade
stimulation or parasympathetic • Slowly titrate meds
HYPERTHYROIDISM: Avoid meds that cause__________– if needed, use
HTN or tachycardia ; smaller doses
HYPERTHYROIDISM Avoid (KAIHEP)
ketamine, pancuronium, halothane, anticholinergic, epi, indirect vasopressors
Hyperthyroidism treat Hypotension with
small doses of phenylephrine
Tachycardia – Esmolol –
gives rapid control (requires careful titration & monitoring, but reverses quickly 10 min. vs. Propranolol 4 hrs.)
Hypovolemic and vasodilated –
• Hyperthermia effect on MAC
titrate meds slowly increases MAC (minimum alveolar concentration)
MAC and temperature relationship
• MAC increases 5% for every degree above 37 ° C
- Hyperthyroidism and Muscle relaxants dosing?
- TTP_____
- _______during attack
- In hyperthyroidism limit use of muscle relaxants due to ______
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
Avoid_____, ______ and ______(SNF)
•why?
Salicylates, NSAIDS, and furosemide
Interfere with total thyroid hormone levels
Thyroid Storm is a
Life-threatening, usually d/t poorly treated hyperthyroidism
In Thyroid storm patient has
• Pt.s have marked sensitivity to increased catecholamine secretion or acute emotional/physical stress
***Thyroid storm Most commonly presents_____ post-op with
6-18 hrs; high mortality rates
Triggering events for Thyroid Storm (TIS MS)
- trauma
- infection
- stroke
- MI
- surgery
Nerve Integrity Monitoring (NIM) Tube increase risk of
LARYNGEAL NERVE DAMAGE
Thyroid Storm Signs/Symptoms
NAHH-DCT
• Nausea/vomiting • Anxiety, agitation, delirium • Hyperthermia • Hypertension • Diffuse abdominal pain/obstruction • CHF/MI or - Tachycardia, arrhythmias
Thyroid storm The tachycardia/arrhythmia is often
resistant to pharmacologic treatment
In Thyroid storm Fever is out of proportion to
any evidence of infection
HTN early, then (In thyroid storm)
CV collapse
Thyroid Storm Treatment (MSH DIC)
- Maintain CV and Ventilatory support
- Supplemental O2
- HR<100 bpm – beta antagonists
- Decrease temp
- Ice packs, hypothermic blankets
- Correct fluid deficits and metabolic abnormalities
Thyroid Storm Treatments
• Don’t take to the OR unless you absolutely have to
• Treat cause/triggers
• Invasive monitoring – A-line, central line, PA
Antithyroid meds, iodine, corticosteroids
• Direct removal of thyroid hormones -TS
Cholestyramine (Bile-salt sequestrants bind thyroid hormones in the intestine and thereby increase their fecal excretion)
Plasmapheresis
Peritoneal dialysis
MH or Thyroid Storm??
dandrolene help both
Hypothyroidism n gastric
Treat delayed gastric emptying and adrenal insufficiency
Hypothyroid post op treatment (DENC)
recovery? extubation? muscle strength and temperature.
- Delayed recovery
- Careful extubation
- Ensure adequate muscle strength & and normothermic before extubation
- Nonopioid analgesics or neuraxial blockade preferred
Complications after Thyroid Surgery Trachea
- Tracheal compression
* 2° to tracheomalacia or hematoma
Complications after Thyroid Surgery
Hypoparathyroidism • Presents with hypocalcemia 24-96 hrs • Signs: TTCCPHL • Tetany, • Chvostek’s sign (nerve twitch) • Trousseau’s sign (latent tetany) • Paresthesia • CHF • Hypotension • Laryngospasm
What is myxedema coma
Myxedema Coma Treatment
• ICU –
-Severe Hypothyroidism mechanical ventilation cardiac support fluids glucose slow warming
Myxedema tx Loading dose of levothyroxine until patient
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.
Myxedema coma monitoring include
Steroids?
- Continuous ECG
- Steroid replacement
- Ex. Hydrocortisone 100mg q 8h
For the Thyroid - Remember:
Airway!!
• Consult endocrinology for urgent/emergent surgery if noneuthyroid
• Treatment of hyperthyroid patients / Avoidance of thyroid storm
Hyperthyroid patients should take their meds the
DOS
Hyperthyroid patients may have
depleted intravascular volumes
Hypothyroid patients CAN MISS A few days of T4 therapy why?
long half life
Heart: Hypothyroid patients have
decreased cardiac output, HR, contractility
Ketone formation,
anion gap acidosis, dehydration and electrolyte abnormalities
• AG calculation formula
Na+− (Cl−+ HCO3−)
DKA Diagnosis: ph? AG? what about K+
arterial pH < 7.30 with anion gap > 12
TOTAL BODY POTASSIUM DEFICIT due to insulin deficiency and Hyperosmolarity, start replacement at 5.3
HHNKS (Hyperosmolar, hyperglycemic nonketotic
syndrome)
HHNKS vs DKA
Severe hyperglycemia ( >600 mg/dL )
• Profound dehydration
• Hyperosmolarity (350 mOsm/kg; nml 275-295)
NO metabolic acidosis or ketone formation
HHNS• PreOperative Tx
- Acquire AM glucose and K+
- Increased cardiac risk
- Consider metoclopromide for treatment of gastroparesis
- Careful mgmt. of preoperative hypoglycemics/insulin
HHNS Intraoperative tx
Intraoperative • Induction: Beware difficult airway, note increased risk of gastroparesis Maintenance • careful attention to positioning • avoid nephrotoxic drugs • q1h glucose checks (via ABG)
Preoperative evaluation of DM
CV
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
Preoperative evaluation of DM
Neurologic
- History of stroke
- Peripheral neuropathy
- Autonomic dysfunction
Preoperative evaluation of DM RENAL
- Renal function
- Diuretic/dialysis dependence
- Volume status
- Skin turgor
- Mucous membranes
- Neck veins
Preoperative evaluation of DM ENDOCRINE
- Glucose control
- Hx of DKA or hyperosmolar syndrm.
- Frequency, severity, & symptoms of hypoglycemic episodes
- Presence of other endocrine disorders
PREOP of DM GI
GI
• Delayed gastric emptying
• Gastroparesis
• GERD
Preop of HEENT
HEENT
• retinopathy
• History of difficult intubation
• Complete airway eval with neck mobility (glycosylation
Labs of Preop DM
Blood glucose
HgbA1C – less than 7%
Electrolytes
• volume, Osmolarity, acid-base status, creatinine for renal status
ECG
Preoperative Considerations DM admission
• Preadmit pts w/ hx DKA or ↑ susceptibility to hypoglycemia and Consult primary or endocrinologist
DM patients should be
First case of the day
Pre-, intra-, postoperative
blood glucose levels should be determine
Type 1 should take a
small amt (1/3 - ½) of their usual morning long-acting insulin on DOS
Type 2 should take
none or up to ½ the dose of long-acting or combo of insulins on DOS
Preop considerations DM
• D/C
All rapid and short-acting insulins
• Short acting oral agents DOS (unless by pump)
Patients with pumps should
continue only basal rate
D/C Sulfonylureas
may be d/c’d several days before surgery d/t long half life
Metformin: when to stop
If renal or hepatic dysfunction then d/c 48 hrs ahea
Postoperative Considerations of DM
- Confusion = R/O hypoglycemia
- Continue any insulin infusions from the OR in the recovery room
- High risk for poor wound healing, infection, pressure ulcers
Pheochromocytoma
Tumors that aris from CHROMAFFIN CELLS of the medulla
• Goal =
prevent effects of catecholamines released by tumor
• HR and BP are essential to monitor
• Calcium channel blockers
Alpha blockade in pheochromocytoma
Phenoxybenzamine, doxazosin, prazosin, terazosin
ALpha first before
beta blockers
Beta-blockade - dysrhythmias or persistent tachycardia; only after several days of
alpha tx to avoid unopposed alpha constriction (usually 10-14 days)
•
• Propranolol, atenolol, metoprolol
• Labetalol – alpha & beta, more beta (1:7)
Pheochromocytoma Drugs that block catecholamine synthesis
• Alpha-methyl-paratyrosine or metirosine
Pheochromocytoma Preop
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
• Less than ____PVC q 5 min (Pheochromocytoma)
1
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
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
Pheochromacytoma Postoperative
• 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
Cushing’s Perioperative Management
- HTN
- Blood glucose
- Normalization of intravascular volume & and electrolytes (Na+)
Perioperative Management of Adrenal
Insufficiency
• Normal daily corticosteroid dose plus supplemental therapy
Perioperative Management of Adrenal
Insufficiency
• Minor procedures:
hydrocortisone 25mg or methylprednisolone 5 mg IV on DOS
Perioperative Management of Adrenal
Insufficiency
Moderate procedures
hydrocortisone 50-75 mg or methylprednisolone 10-15mg IV on DOS then tapered over 1-2 days
Perioperative Management of Adrenal
Insufficiency
• Major procedures:
hydrocortisone 100-150mg or methylprednisolone 20-30mg on DOS then taper
Acromegaly
Excess growth hormone
With acromegaly expect
- Difficult Airway
- Distorted face with mandibular expansion
- Enlarged tongue
- Enlarged epiglottis
- Overgrowth of cricoarytenoid joints
- Vocal cord dysfunction
- Enlarged nasal turbinates
Increase risk of __________ with acromegaly
postop resp failure
Pituitary Surgery & Preoperative Anesthetic
Considerations
Most common is __________
Obtain _______concentrate on ________
• 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
• Labs for pituitary surgery preop
include glucose, electrolytes, & hormone levels, type and cross
_______should be evaluated
• Tumor invasion
Pituitary Surgery & Intraoperative Anesthetic
Considerations
•
- Invasive monitoring
- Aline – BP and labs
- Central line if major hemodynamic changes
Pituitary Surgery & Intraoperative Anesthetic
Considerations
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
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
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
Hypercalcemia
• Hypercalcemia =
__________ may also be seen
• Hypocalcemia = __________
ECG – interval changes; signs of dysfunction
• Hypercalcemia = shortened QT interval
Osborn (J waves) may also be seen
• Hypocalcemia = prolonged QT
Anesthetic Management of
Hyperparathyroidism
For Surgical parathyroidectomy
Pre-op
- Preoperative
- Potential cardiac, neurologic, & renal dysfunction
- ECG, neurologic exam, electrolytes
- Medical correction of extremely high serum calcium levels
Anesthetic Management of
Hyperparathyroidism
• For Surgical parathyroidectomy
• Intraoperative
• Careful titration of muscle relaxants – may be more sensitive
Anesthetic Management of
Hyperparathyroidism
• For Surgical parathyroidectomy
• Postoperative
Serum calcium levels should normalize in 1-3 days
• May see acute hypocalcemia
Anesthetic Management of Hyperparathyroidism
• Recurrent laryngeal nerve injury
Innervates the intrinsic muscles of the larynx
• Partial injury can affect abductor fibers
Anesthetic Management of Hyperparathyroidism
Unilateral recurrent laryngeal nerve palsy
- One vocal cord unable to abduct or adduct
* Hoarseness/stridor
Anesthetic Management of Hyperparathyroidism
Bilateral recurrent laryngeal nerve palsy
- Inability to abduct or adduct vocal cords
* May be life threatening & require intubation
SLN damage:
hoarseness d/t paralysis of cricothyroid muscle, at risk for aspiration (loss of sensation above cords
RLN damage:
- Unilateral – hoarseness
* Bilateral – airway obstruction and aphonia
T3 is
Four times more potent than T4
