Final Exam Review Flashcards
___ glands are organs that secrete hormones
Endocrine
What are (4) types of hormones?
- Peptide/protein hormones
- Catecholamines
- Steroid hormones
- Thyroid hormones
What is the most common type of hormone in the body? Examples of this type of hormone include insulin, growth hormone, and antidiuretic hormone
Peptide/protein hormones
___ hormone > 100 amino acids
Protein
___ hormone < 100 amino acids
Peptide
This type of hormone is produced by the adrenal medulla; examples = adrenaline, norepinephrine
Catecholamines
This type of hormone is secreted by the adrenal cortex; examples = cortisol, aldosterone, ovaries/testes
Steroid hormones
This type of hormone is anything derived from tyrosine; examples = T3, T4
Thyroid hormones
Peptide/protein hormones and catecholamines are ___ soluble
Water soluble
Steroid and thyroid hormones are ___ soluble
Fat soluble
___ feedback loop = the hormone itself sends the signal to STOP production/release of hormone when there is enough
Negative feedback loop
Example of a positive feedback loop = ___ hormone
Lutenizing hormone
LH and positive feedback—LH acts on the ovaries to cause secretion of ___; ___ (more/less) LH is secreted to secrete more estrogen
Secretion of estrogen; more LH is secreted to secrete more estrogen
___ = all of the chemical reactions in the body
Metabolism
___ = energy during resting conditions
Basal metabolic rate
Basal metabolic rate accounts for ___-___% of daily energy expenditure
50-70%
Basal metabolic rate ___ (increases/decreases) with age
Decreases
___ is the end product of almost all the energy released in the body
Heat
Metabolic rate is quantitatively measured in ___
Calories
The following factors ___ (increase/decrease) metabolic rate: thyroxine, testosterone, growth hormone, fever
Increase
The following factors ___ (increase/decrease) metabolic rate: inadequate thyroxine (hypothyroidism), sleep, malnutrition
Decrease
___ is responsible for temperature regulation
Hypothalamus
What specific part of the hypothalamus controls temperature regulation?* KNOW FOR BOARDS
Anterior hypothalamus—preoptic nuclei
Shivering increases O2 consumption up to ___%
Up to 300%
Hypothermia—PVR ___ (increases/decreases)
Increases
Hypothermia—renal effects = ___ = ___ (increased/decreased) plasma volume
Diuresis = decreased plasma volume
Hypothermia—cerebral O2 consumption ___ (increases/decreases); MAC ___ (increases/decreases)
Decreases; decreases
Hypothermia causes MAC to decrease ___-___% per degree C
5-7%
Hypothermia results in delayed ___
Emergence
Hypothermia ___ (increases/decreases) clotting factors/platelets
Decreases
Hypothermia ___ (increases/decreases) metabolism; ___ NMB; ___ emergence
Decreases metabolism; prolongs NMB; delays emergence
Hypothermia ___ healing; risk for infection is ___ (increased/decreased)
Delays healing; risk for infection is increased
What are the two body compartments?
Peripheral compartment and core compartment
___ compartment = limbs, skin, subcutaneous tissue; ___ of body’s heat content
Peripheral compartment; 1/3 of body’s heat content
___ compartment = major thoracic and abdominal organs + brain; ___ of body’s heat content
Core compartment; 2/3 of body’s heat content
Vasoconstriction during anesthesia will cause periphery to go down to 30-32 C to maintain core temp at 37 C—T/F?
True
___ = principle byproduct of metabolism
Heat
Shivering can increase heat production by ___%
300%
Body heat is preserved by peripheral vaso___
Vasoconstriction
What are (4) mechanisms of heat loss? (in order from greatest amount of heat loss to least)
- Radiation (40%…ppt says 60%)
- Convection (30%)
- Conduction (20%)
- Evaporation (10%)
What type of heat loss is this?—greatest amount of heat loss; amount of heat loss is determined by the difference in temperature between body/surroundings
Radiation
What type of heat loss is this?—heat loss via air currents; degree of heat loss depends on amount of body surface area exposed/airflow
Convection
What type of heat loss is this?—heat loss via direct contact (i.e.: OR table)
Conduction
What type of heat loss is this?—skin prep, open abdominal cavities, respiration
Evaporation
Anesthesia (both general and regional) inhibits peripheral vasoconstriction—T/F?
True
Biggest drop in body temperature is during the first hour after induction; there is a 1-2 degree C decrease in core temperature because of peripheral vasodilation—T/F?
True
Most heat loss occurs in proportion to exposed ___
Exposed body surface area
General anesthesia promotes vaso___, ___ (increases/decreases) metabolic rate/heat production, and ___ (increases/decreases) hypothalamic responsiveness to hypothermia
Vasodilation, decreases metabolic rate/heat production, and decreases hypothalamic responsiveness to hypothermia
NMBs prevent shivering—T/F?
True
Heat loss is more pronounced with ___ and ___ patients (think age extremes)
Elderly and neonatal
Neonatal patients have a ___ (lower/higher) body surface area based on their weight, which causes ___ (more/less) heat loss
Higher body surface area, causes more heat loss
Sweating leads to heat loss/cooling and must be prevented—T/F?
True
What is the most commonly used drug to treat post-op shivering?
Demerol
What disorder is this?—rare, usually inherited disorder of skeletal muscle; results in a hypercatabolic state…tachycardia, hypercapnia, muscle rigidity, tachyarrhythmias, metabolic acidosis
Malignant hyperthermia
Drug/dose to treat malignant hyperthermia = ___
Dantrolene 2.5 mg/kg every 5 minutes until symptoms subside
Max dose of dantrolene = ___
10 mg/kg
Even if patient had a previous uneventful surgery, they can still develop MH in the future—T/F?
True
MH triggers = ___
All inhalation agents + succs
Nitrous oxide can cause MH—T/F?
False! Nitrous is safe
Locals, propofol, non-depolarizing NMBs, benzos, and barbituates are all safe to use in patients with a history of MH—T/F?
True
___ gland = the “master gland”
Pituitary
___ = the coordinating center of the endocrine system
Hypothalamus
This organ delivers signals to the pituitary gland, and the pituitary gland releases hormones that influence other endocrine systems
Hypothalamus
Hypothalamus + pituitary gland = ___ axis
Hypothalamic-pituitary adrenal (HPA) axis
The HPA axis lives inside the BBB—T/F?
False—HPA axis lives OUTSIDE the BBB
What are the (6) main hormones secreted from the anterior pituitary gland? (FLAT PIG)
- Follicle stimulating hormone
- Lutenizing hormone
- Adrenocorticotropic hormone
- Thyroid stimulating hormone
- Prolactin
- I—ignore
- Growth hormone
Pituitary gland rests in the ___ bone in area called the ___
Sphenoid bone in area called the sella turcica
What are (4) divisions of the pituitary gland?
- Adenohypophysis
- Pars intermedius
- Pars tubularis
- Neurohypophysis
Adenohypophysis = ___ pituitary; ___ (smallest/largest) part of the pituitary gland
Anterior pituitary; largest part of the pituitary gland
Pars intermedius = gone after ___
Fetal development
Pars tubularis = highly ___, no known hormones secreted
Vascular
Neurohypophysis = ___ pituitary
Posterior
Anterior vs. posterior pituitary—anterior pituitary is more of a ___ connection
Vascular/glandular connection
Anterior vs. posterior pituitary—posterior pituitary is more of a ___ system connection
Nervous system/glial connection
Posterior pituitary only secretes ___ and ___ ONLY
Oxytocin and antidiuretic hormone ONLY
Hormones secreted by the posterior pituitary are produced by the ___, transfer down nerve fibers, and are stored/released from the ___
Produced by the hypothalamus and stored/released from the posterior pituitary
Anterior pituitary is also called the ___
Adenohypophysis
Anterior pituitary is connected to the hypothalamus via a ___ network
Portal venous network
___ = capillary beds connected; this is how signals are transferred from the hypothalamus down to the anterior pituitary gland
Portal venous network
(5) anterior pituitary cell types (in order of percentage in the body):
- Somatotropes (30-40%)
- Corticotropes (20%)
- Thyrotropes (3-5%)
- Gonadotropes (3-5%)
- Lactotropes (3-5%)
Somatotropes—___-___%; secrete ___
30-40% MOST ABUNDANT***; secrete growth hormone
Corticotropes—___%; secrete ___
20%; secrete ACTH
Thyrotropes—___-___%; secrete ___
3-5%; secrete TSH
Gonadotropes—___-___%; secrete ___ and ___
3-5%; secrete LH and FSH
Lactotropes—___-___%; secrete ___
3-5%; secrete prolactin
Posterior pituitary is AKA ___
Neurohypophysis
Posterior pituitary produces only ___ hormones
2
Posterior pituitary produces ___ and ___
Oxytocin and vasopressin (AKA ADH—antidiuretic hormone)…regulate uterine contractions/water balance
Blood supply of hypothalamus/pituitary gland—___ is supplied by the superior hypophyseal artery
Hypothalamus
Blood supply of hypothalamus/pituitary gland—___ is venous by the way of long portal vessels
Anterior pituitary
Blood supply of hypothalamus/pituitary gland—___ is supplied by the inferior hypophyseal artery
Posterior pituitary
What are two nuclei in the posterior pituitary?
- Paraventricular nucleus
- Supraoptic nucleus
What nucleus is this?—lies above the third ventricle of the brain; produces and transports oxytocin via nerve fibers to the posterior pituitary
Paraventricular nucleus
What nucleus is this?—lies above the optic chiasm/nucleus; produces and transports ADH (vasopressin) via nerve fibers to the posterior pituitary
Supraoptic nucleus
This hormone is synthesized in the supraoptic nucleus; increases permeability of collecting ducts, increasing free water absorption
Vasopressin (ADH)
Vasopressin (ADH)—___ (increases/decreases) urine osmolality; ___ (increases/decreases) plasma osmolality; ___ (increases/decreases) ECF volume
Increases urine osmolality; decreases plasma osmolality; increases ECF volume
Vasopressin (ADH) causes contraction of vascular smooth muscle, producing a vasoconstrictive pressor effect (more prevalent in large doses)—T/F?
True
Vasopressin (ADH) acts on what (2) receptors?
- V1 receptor
- V2 receptor
___ receptor = pressor effect; vasoconstriction; direct effect on increasing arterial BP; prevalent with extreme increases in circulating levels, i.e.: hemorrhage
V1
___ receptor = ADH effect (reabsorption of water); indirect way of increasing BP by increasing blood volume
V2
Would see an increase in vasopressin/ADH from: ___ II; ___ stimulation; ___osmolarity; ___volemia; ___tension
Angiotensin II (RAAS system); sympathetic stimulation; hyperosmolarity; hypovolemia; hypotension
Stimulus for vasopressin/ADH release: osmoreceptor in hypothalamus is activated by plasma osmolality > ___ mosm/L
> 290 mosm/L
Normal plasma osmolality = ___-___
285-290
Once plasma osmolality > 290, hypothalamus sends signals of ___
Thirst
Vasopressin release—___ (increased/decreased) ECF volume
Decreased
Vasopressin release—___ (increased/decreased) Na
Increased
Vasopressin release—___ (increased/decreased) BP
Decreased
Nicotine stimulates vasopressin release—T/F?
True—sympathetic stimulation
Nausea, pain, and stress can cause vasopressin release—T/F?
True
Positive pressure ventilation can cause vasopressin release—T/F?
True
Without ADH, urine output is ___
Excessive
Diabetes insipidus (DI)—___ thirst, ___ urine
Excessive thirst, dilute urine
___ deficiency causes DI
ADH deficiency
Two types of DI:
- Central/neurogenic DI
- Nephrogenic DI
What type of DI is most common?
Central/neurogenic DI
___ DI is common post head injury or pituitary surgery
Central/neurogenic DI
___ DI results from the inability of the kidney to respond to ADH (i.e.: chronic renal disease, lithium toxicity, hypercalcemia, hypokalemia)
Nephrogenic DI
DI results in excretion of large amounts of ___osmotic urine with ___osmotic plasma and ___dipsia, ___uria, without hyperglycemia
Large amounts of hypoosmotic urine with hyperosmotic plasma and polydipsia, polyuria without hyperglycemia
Treatment of DI = limit ___ intake and give ___
Limit sodium intake and give synthetic ADH (DDAVP)
DI can cause ___natremia d/t excessive water loss
Hypernatremia
Hypernatremia from DI ___ (increases/decreases) MAC
Increases
Hypovolemia from DI requires ___ (increased/decreased) doses of IV agents
Decreased
Postpone elective surgery for Na > ___
150
Symptoms of ___natremia = restlessness, lethargy, hyperreflexia; can proceed to seizures, coma, death
Hypernatremia
Rapid correction of hypernatremia results in seizures, brain edema, permanent neurologic damage, and death—T/F?
True
SIADH =
Syndrome of inappropriate antidiuretic hormone…ADH overload
SIADH—autonomous release from pituitary (or tumor) causes water ___, ___natremia, ___ urine, ___osmolar plasma
Water retention, hyponatremia, concentrated urine, hypoosmolar (dilute) plasma
Causes of SIADH = CNS disorders/head trauma, SCC of lung, pulmonary infection, pituitary surgery—T/F?
True
Signs of SIADH = water ___, ___ hyponatremia, ___ edema causing CNS effects—lethargy, seizures, coma
Water intoxication, dilutional hyponatremia, brain edema
Treatment of SIADH = treat ___, fluid ___
The underlying cause, fluid restriction
What tetracycline antibiotic can be used to treat SIADH?
Demeclocycline—decreases the body’s responsiveness to ADH
Hyponatremia—usually asymptomatic until at a sodium level of ___ meq/L
125
Serious symptoms of hyponatremia result at levels below ___ meq/L
Below 120
Na > ___ safe for elective procedures
> 130
Na < ___ may lead to cerebral edema
< 130
Intraoperatively, hyponatremia causes a ___ (increase/decrease) in MAC
Decrease
Postoperatively, hyponatremia can cause ___, ___, ___ (think neuro symptoms)
Agitation, confusion, somnolence
Treatment of hyponatremia = ___% saline, ___ (sometimes used)
Hypertonic 3% saline, lasix sometimes used
Hyponatremia must be corrected slowly—recommended correction is 1-2 meq/L/hr or < 12 meq/L in 24 hours—T/F?
True
Rapid correction of hyponatremia can result in central ___
Central pontine myelinolysis
Monitor serum Na+ every ___ hours during treatment of hyponatremia
1-2 hours
Oxytocin (pitocin) is secreted from the ___ nucleus of the posterior pituitary
Paraventricular
Oxytocin (pitocin) causes ___ of the uterus during labor (and can be used to contract uterus to decrease blood loss after birth)
Contraction
Oxytocin also causes contraction of the myoepithelial cells of the ___
Lactating breast
Oxytocin/milk release is an example of a ___ loop
Positive-feedback
Pituitary tumors are often found as a result of compression on adjacent structures, such as visual changes with impingement of the optic chiasm—T/F?
True
Compression of optic chiasm from pituitary tumor can result in bitemoral hemianopsia, which is loss of ___ in both eyes
Peripheral vision
Patients undergoing pituitary resection should undergo evaluation of their hormonal function to detect either ___ or ___
Hypersecretion or panhypopituitarism
Pituitary tumors = hypersecretion of ___, ___, ___
GH, TSH, ACTH
Panhypopituitarism = ___ (high/low) levels of hormones, have to provide ___
Low levels of hormones, have to provide hormone replacement
Acromegaly = too much ___; difficult ___, ___
Too much GH; difficult mask, intubation
Hyperthyroid = too much ___; ___cardia, ___ loss
Too much TSH; tachycardia, weight loss
Cushing’s disease = too much ___; difficult ___ and ___
Too much ACTH; difficult airway and access
Panhypopituitarism = need hormone replacement with ___, ___, ___
Cortisol, levothyroxine, DDAVP
Most pituitary resection are done with ___ approach
Trans phenomenal
Patients may develop ___ d/t loss of ADH from pituitary tumor surgery; may be temporary or permanent; may be evident intraop or postop
DI
Suspect DI in patients after pituitary tumor resection with ___ urine output; confirm with urine specific gravity < ___
High urine output; confirm with urine specific gravity < 1.005
Treat DI with ___ and ___ replacement
DDAVP and volume replacement
Acromegaly = ___ hypersecretion after adolescence
Somatotropin/growth hormone
Patients with acromegaly will be difficult ___/___, have ___ (small/large) tongue and epiglottis, ___ mandible, ___ facial features
Difficult mask/intubation, have large tongue and epiglottis, enlarged mandible, distorted facial features
Patients with acromegaly will have ___ narrowing and vocal cord ___
Sub glottic narrowing and vocal cord enlargement
Patients with acromegaly, may consider downsizing ETT by ___
0.5
___ is common in patients with acromegaly
OSA
REVIEW posterior pituitary—___ secretes hormones that are transferred and stored in ___ and released when needed; only 2 hormones secreted by posterior pituitary = ___ and ___
Hypothalamus secretes hormones that are transferred and stored in posterior pituitary and released when needed
Only 2 hormones secreted by posterior pituitary = oxytocin and ADH (vasopressin)
REVIEW anterior pituitary—___ sends either releasing or inhibitor signals to anterior pituitary; AP has ___ different cell types that can release ___ different hormones in response to signals sent from hypothalamus
Hypothalamus; 5 different cell types; release 6 different hormones
Adrenal glands are located on top of the ___
kidneys
Adrenal glands are AKA the ___ glands
suprarenal
Two parts of the adrenal glands = ___ and ___
cortex and medulla
Adrenal cortex = ___ layer; makes up ___-___% of the adrenal gland; synthesizes more than ___ different types of ___ hormones
outer layer; makes up 80-90% of the adrenal gland; synthesizes more than 30 different types of steroid hormones (corticosteroids)
Adrenal medulla = ___ or ___ region; makes up ___-___% of the adrenal gland
core or inner region; makes up 10-20% of the adrenal gland
What are the (3) layers of the adrenal cortex?
- Zona glomerulosa
- Zona fasciculata
- Zona reticularis
Zona glomerulosa = ___ layer
outermost
Zona fasciculata = ___ layer
middle layer
Zona reticularis = ___ layer
inner layer
Zona glomerulosa produces ___
mineralocorticoids, i.e.: aldosterone
Zona fasciculata produces ___
glucocorticoids, i.e.: cortisol
Zona reticularis produces ___
androgens, i.e.: DHEAS (dehydroepiandrosterone)–has similar effects to testosterone
Adrenal medulla lies underneath the adrenal ___; secretes ___–___% epinephrine, ___% norepinephrine
underneath the adrenal cortex; secretes catecholamines; secretes 80% epinephrine, 20% norepinephrine
Adrenal cortex mediates the stress response via the production of substances known as ___ and ___
mineralocorticoids and glucocorticoids
This zone of the adrenal cortex produces mineralocorticoids like aldosterone
zona glomerulosa
This zone of the adrenal cortex produces glucocorticoids like cortisol
zona fasciculata
This zone of the adrenal cortex produces androgens like DHEAS; it is a secondary site of androgen synthesis
zona reticularis
Aldosterone, cortisone, and testosterone are all ___ hormones; all are synthesized from ___
steroid hormones; all are synthesized from cholesterol
Mineralocorticoids = ___
aldosterone
Mineralocorticoids control minerals, AKA ___
electrolytes–sodium and potassium
Primary mineralocorticoid is ___
aldosterone–90%
Aldosterone affects ___ balance, which regulates blood pressure
salt/water balance
RAAS review–kidneys release ___ in response to hypovolemia»_space; ___ is released by the liver and converts renin into ___»_space; ___ is converted to ___ by ACE (which is released from the lungs)»_space; ___ [potent vasoconstrictor] stimulates release of ___ from the adrenal gland»_space; ___ causes retention of sodium and water, excretion of potassium, and increases BP
kidneys release renin in response to hypovolemia»_space; angiotensinogen is released by the liver and converts renin into angiotensin I»_space; angiotensin I is converted to angiotensin II by ACE (which is released from the lungs)»_space; angiotensin II [potent vasoconstrictor] stimulates release of aldosterone from the adrenal gland»_space; aldosterone causes retention of sodium and water, excretion of potassium, and increases BP
Anything that causes a drop in ECF (i.e.: hemorrhage) will cause release of ___ from the kidneys and thus kick off the ___ system
release of renin from the kidneys and thus kick off the RAAS system
Aldosterone primarily affects the principle cells of the ___ and collecting ducts of the kidneys
distal convoluted tubule
Aldosterone causes the retention of ___ and ___; excretion of ___ and ___
retention of sodium and water; excretion of K+ and H+
When aldosterone is unopposed, it leads to ___tension, extracellular fluid ___, ___kalemia, ___osis
hypertension (d/t sodium and water retention), extracellular fluid expansion (d/t sodium and water retention), hypokalemia (d/t K+ excretion), alkalosis (d/t H+ excretion)
What are two potent controllers of aldosterone secretion?–serum ___ and ___
serum potassium and angiotensin II
Primary hyperaldosteronism is AKA ___ syndrome
Conn’s syndrome
Conn’s syndrome is caused by ___ secreting tumors or hyperplasias
aldosterone secreting tumors or hyperplasias
Treatment of Conn’s syndrome is successful for tumors because they are usually unilateral–once you remove the tumor, patient is cured–T/F?
True
Patients with adrenal hyperplasia usually require pharmacological intervention with medications such as spironolactone–K+ sparing diuretic–T/F?
True because the excess aldosterone causes K+ excretion
Conn’s syndrome effects [think too much aldosterone]–___ (increased/decreased) ECF volume; ___tension; K+ ___; metabolic ___osis
increased ECF volume; hypertension; K+ depletion; metabolic alkalosis
Diagnosis of conn’s syndrome = ___ (high/low) renin from negative feedback
low renin–kidneys stop secreting renin in response to high levels of aldosterone
Treatment of conn’s syndrome = ___ or ___ management
surgical or medical management
Secondary hyperaldosteronism = excess of aldosterone ___ of the adrenal gland
OUTSIDE of the adrenal gland (i.e.: abdominal tumor outside of the adrenal gland)
In secondary hyperaldosteronism, ECF is lost to the ___; intravascularly, patients are ___ despite total volume ___; this triggers release of ___ by kidneys; release of ___ exacerbates fluid/sodium retention
ECF is lost to the extravascular space; intravascularly, patients are volume depleted despite total volume overload; this triggers release of renin by kidneys; release of renin exacerbates fluid/sodium retention
In primary and secondary hyperaldosteronism, want to restrict ___ and ___
fluids and sodium
___ (low/high) potassium levels in primary and secondary hyperaldosteronism can cause muscle weakness and ___ (increase/decrease) sensitivity to NMBs
low potassium levels in primary and secondary hyperaldosteronism can cause muscle weakness and increase sensitivity to NMBs
Hypoaldosteronism = adrenal ___
insufficiency
Hypoaldosteronism–___ lost in the urine, ___ retained; plasma volume ___ (increases/decreases); ___tension and ___kalemia may lead to circulatory collapse
Na+ lost in the urine, K+ retained; plasma volume decreases; hypotension and hyperkalemia may lead to circulatory collapse
Glucocorticoids = ___
cortisol
Cortisol is also called ___
hydrocortisone
___ is the principle glucocorticoid (95%) and is produced in the zona ___
cortisol is the principle glucocorticoid and is produced in the zona fasciculata
HPA axis and release of cortisol–hypothalamus sends ___ releasing hormone to the ___; ___ pituitary releases ___ to stimulate the adrenal glands to release ___ during stress; when levels are high, the negative feedback loop sends signals back to the hypothalamus to suppress its release
hypothalamus sends corticotropin-releasing hormone to the anterior pituitary; anterior pituitary releases ACTH to stimulate the adrenal glands to release cortisol during stress
___ hormone stimulates cortisol secretion almost entirely
adrenocorticotropic hormone (ACTH)
ACTH release is controlled by ___ releasing hormone from the ___
corticotropin releasing hormone from the hypothalamus
Physiologic stress causes release of both ___ and ___
ACTH and CRH
High cortisol levels cause ___ of ACTH and CRH release (negative feedback)
inhibition
CRH, ACTH, and cortisol are released in relation to circadian rhythms, with highest levels in the morning to change from a sleep to waking period–T/F?
True
Effects of glucocorticoids [cortisol]–stimulate ___neogenesis; ___ (increases/decreases) glucose utilization by cells; ___ (increases/decreases) blood glucose concentration
stimulate gluconeogenesis; decreases glucose utilization by cells; increases blood glucose concentration
High levels of cortisol have ___ effects
anti-inflammatory
Cortisol ___ healing and is useful in ___ processes, ___ reactions, ___, and organ ___
cortisol enhances healing and is useful in autoimmune processes (i.e.: lupus, RA, inflammatory bowel diseases like Crohn’s), allergic reactions, asthma, and organ transplant
Very high doses of cortisol are often used to assist in preventing organ rejection–T/F?
True
Almost any stress (physical or neurogenic) can cause an immediate release of ACTH by the anterior pituitary gland, followed by greatly increased secretion of cortisol–T/F?
True
The adrenal medulla is ___ connected to the sympathetic nervous system via ___ nerve fibers
directly connected to the SNS via ventral nerve fibers
Short-term stress response is a very ___ response; adrenal ___ releases catecholamines
very rapid response; adrenal medulla releases catecholamines–epi and norepi
Long-term stress response is a ___ response; adrenal ___ releases ___corticoids and ___corticoids
slower response; adrenal cortex release mineralocorticoids (aldosterone) and glucocorticoids (cortisol)
Short-term stress response–___ (increased/decreased) heart rate; ___ (increased/decreased) BP; liver converts glycogen to ___ and releases it into blood; ___ of bronchioles; ___ (increased/decreased) digestive system activity/urine output; ___ (increased/decreased) metabolic rate
increased heart rate; increased BP; liver converts glycogen to glucose and releases it into blood; dilation of bronchioles; decreased digestive system activity/urine output; increased metabolic rate
Long-term stress response–retention of ___ and ___ by kidneys; ___ (increased/decreased) blood volume and BP; proteins/fats converted to ___ or broken down for energy; ___ (increased/decreased) blood glucose; ___ of immune system
retention of sodium and water by kidneys; increased blood volume and BP; proteins/fats converted to glucose or broken down for energy; increased blood glucose; suppression of immune system
Cushing’s syndrome–caused by excessive ___ secretion
cortisol
Cushing’s syndrome causes can be ___ dependent or ___ dependent
ACTH dependent or non-ACTH dependent
Causes of Cushing’s syndrome–ACTH secreting ectopic tumor (most often located in the ___ as ___); overactive hypothalamic secretion of ___; primary glucocorticoid secreting ___ tumor
- ACTH secreting ectopic tumor (most often located in the lung as SCC)
- overactive hypothalamic secretion of corticotropin-releasing hormone
- primary glucocorticoid secreting adrenal tumor
What is the most common cause of Cushing’s syndrome?
Iatrogenic–from chronic administration of glucocorticoids
Cushing’s syndrome may make patient more sensitive to ___, so use conservative approach
NMBs
___tension is very common in Cushing’s syndrome
Hypertension
Cushing’s syndrome and anesthesia considerations–___ is common in these patients
OSA
Cushing’s syndrome and anesthesia considerations–___ is often difficult d/t excess fat deposits not only on the head/neck, but also on the upper back
intubation
Cushing’s syndrome and anesthesia considerations–___ becomes difficult d/t fat deposits on upper back
positioning
Cushing’s syndrome and anesthesia considerations–patients often have ___ skin/___ bones–careful positioning is imperative to prevent skin breakdown and pathologic fractures with any mild trauma
patients often have frail skin/brittle bones
Cushing disease is caused by ACTH secreting tumor of the ___ gland
pituitary gland
In Cushing disease, ___ is the primary cause
pituitary
The term Cushing’s syndrome is used to describe all causes of cortisol excess, while Cushing disease specifically relates to the ___ as the primary cause
pituitary–pituitary tumor is releasing too much ACTH
Addison’s disease results from failure to produce ___ hormones
adrenocortical hormones–glucocorticoids and mineralocorticoids
Primary Addison’s disease = ___ non-function, destruction of the ___ gland, mostly auto___
adrenal non-function, destruction of the adrenal gland, mostly autoimmune
What are (3) of the most common causes of primary Addison’s disease?
- TB
- AIDS
- Fungal infections
Treatment of primary Addison’s disease = replace ___ deficiency
replace glucocorticoid/mineralocorticoid deficiency
In primary Addison’s disease, the pituitary-adrenal axis stays intact–T/F?
True
Secondary Addison’s disease is caused by ___ or ___ dysfunction
hypothalamic or pituitary dysfunction (d/t chronic glucocorticoid therapy or removal of pituitary tumor)
Nearly 100% of patients with glucocorticoid deficiency will experience ___
anorexia
Symptoms of glucocorticoid deficiency in Addison’s disease: ___glycemia; ___; ___ness; weight ___; ___pigmentation (primarily from increased ACTH); severe ___ in response to stress
hypoglycemia; fatigue; weakness; weight loss; hyperpigmentation; severe deterioration in response to stress
Symptoms of mineralocorticoid deficiency in Addison’s disease: ___hydration; ___uria; ___tension; ___ Na; ___ K; metabolic ___osis
dehydration; polyuria; hypotension; low Na; high K; metabolic acidosis
Addisonian crisis = ___ collapse
CV collapse
Treat addisonian crisis with ___
cortisol
If addisonian crisis is left untreated, death may result in 4 days to 2 weeks–T/F?
True
Treatment of Addison’s disease, primary or secondary = ___ + ___
glucocorticoids + mineralocorticoids
Patients who are on chronic steroids need a dose before surgery; periop shock or death can occur if steroids are not given d/t adrenal insufficiency–T/F?
True
Patients on chronic steroids can’t increase their cortisol release in response to stress (i.e.: hypotension during surgery), and CV collapse can occur–T/F?
True
Minor surgery requires stress dose steroids–T/F?
False–minor surgery typically does NOT require stress dose steroids
Moderate surgeries often receive ___ mg ___
50 mg hydrocortisone
Major surgeries receive ___ mg ___ with tapering
100 mg hydrocortisone with tapering
Etomidate is an induction drug used for hemodynamically ___ patients
hemodynamically unstable
Etomidate causes profound suppression of ___ for at least 24 hours and can contribute to ___ and resultant ___tension
profound suppression of cortisol for at least 24 hours and can contribute to adrenal insufficiency and resultant hypotension
Because etomidate can cause adrenal insufficiency, it should be used sparingly in patients with ___
septic shock
The adrenal medulla is connected ___ to the sympathetic nervous system via nerves; the ___ portion of the spinal cord goes directly into the adrenal medulla to stimulate the release of epi/norepi
directly; ventral portion
The adrenal medulla bridges the ___ and ___ nervous systems
endocrine and sympathetic nervous systems
Catecholamines are made by ___ cells in the adrenal medulla
chromaffin cells
All catecholamines are derived from ___
tyrosine
The synthesis of norepinephrine begins with hydroxylation of ___ to ___
tyrosine to dopa
___ is the principle product of the adrenal medulla
Epinephrine
Epinephrine is only made in the ___
adrenal medulla
Epinephrine accounts for nearly ___% of the adrenal medulla’s output; the other 20% is ___
80%; other 20% is norepinephrine
The enzyme Phenylethanolamine N-Methyltransferase (PNMT) is the enzyme responsible for the transformation of ___ into ___
transformation of norepinephrine into epinephrine
Adrenal medulla = modified ___ ganglion
modified sympathetic ganglion
Preganglionic sympathetic neuron [in the sympathetic nervous system/spinal cord] is directly connected to the ___
adrenal medulla
The ___ neuron is located directly inside the adrenal medulla
postganglionic neuron
Adrenal medulla houses the ___ nerve
postganglionic nerve
Epinephrine and norepinephrine both have strong ___ effects, which results in arterial vasoconstriction
strong alpha-1 effects
Epinephrine has stronger ___ effects, which increases ___ and ___ more
stronger beta-1 effects, which increases heart rate and contractility
Epi affects every alpha/beta receptor–alpha-1, alpha-2, beta-1, beta-2–T/F?
True
Norepi has minimal effects on ___ receptors
beta-2 receptors
___ is the enzyme necessary for conversion of norepinephrine to epinephrine
PNMT–phenylethanolamine N-methyltransferase
PNMT expression is influenced by ___, which helps account for their role in affecting blood pressure
glucocorticoids (cortisone)
___ is the only important endocrine disease associated with the adrenal medulla
pheochromocytoma
___ is a tumor either caused by adrenal medullary hyperplasia or extra-adrenal chromaffin tissue
pheochromocytoma
Pheochromocytoma is a tumor that makes ___ in an unregulated fashion
catecholamines
Symptoms of pheochromocytoma–paroxysmal ___
paroxysmal hypertension
Paroxysmal hypertension = ___ and ___ high blood pressure
episodic and volatile high BP
Most of the time with pheochromocytoma, HTN is ___, but it can exist paroxysmally
HTN is constant
During true paroxysmal HTN, BP can increase to extremely high levels, potentially causing stroke or MI–T/F?
True
Most tumors in pheochromocytoma are solitary tumors localized to a single adrenal gland (mostly to the right)–T/F?
True
Of pheochromocytoma tumors that are extra-adrenal (10%), 95% are in the ___
abdomen
Urinary ___ levels help to make the diagnosis of pheochromocytoma, as both ___ and ___ are degraded to this
Urinary Vannilylmandelic acid (VMA), as both epi and norepi are degraded to this
What enzyme breaks down catecholamines epi and norepi to VMA?
COMT–catechol-O-methyltransferase
What is the other enzyme that breaks down epi/norepi, but is less important than COMT?
MOA–monoamine oxidase
Management of pheochromocytoma–establish ___ block before ___ block to prevent ___
alpha block before beta block to prevent unopposed alpha mediated vasoconstriction/accelerated HTN
Alpha blockers (phenoxybenzamine or prazosin) should be started ___-___ days prior to surgery to normalize BP
10-14 days
Phenoxybenzamine is a ___-acting alpha blocker (lasts for ___-___ hours) and is ___-selective (blocks alpha 1 and 2)
long-acting alpha blocker (lasts for 24-48 hours) and is non-selective
Prazosin is a ___ alpha blocker
selective–blocks alpha 1 only
If you beta block before alpha block is established, it can lead to immediate ___ shock, so always give alpha blockade before beta blockade
immediate cardiogenic shock
If patient comes into ER with pheochromocytoma and alpha blocking therapy isn’t possible, ___ can be used during induction of anesthesia; ___ such as Cardene have also been used and titrated to effect
nitroprusside can be used; calcium channel blockers such as Cardene have also been used
___-acting vasoactive agents are desirable during adrenalectomy, as paroxysms of both hypotension and hypertension are common when the tumor is manipulated or removed
Short-acting
Avoid ___-releasing agents, ___, and ___ because these agents provoke pheochromocytoma
histamine-releasing agents, metoclopramide, and glucagon
Pheochromocytoma–when the tumor is removed, abrupt ___ may occur
hypotension
When tumor is removed, treat hypotension with ___ and ___
IVF and vasopressors
Adrenalectomy–catecholamine levels return to normal several days after surgery, and approximately 75% of patients become normotensive within ___ days postop
10 days
Medullary hyposecretion–physiologic effect is not a serious problem; the sympathetic nervous system compensates for CV regulation; and other regulatory hormones compensate for metabolic effects–T/F?
True
___ = glands secreting digestive juices into the duodenum
Acini
(4) cell types in the islet of langerhans:
- Alpha cells
- Beta cells
- Delta cells
- Pancreatic polypeptide cells
___ cells secrete glucagon
alpha
___ cells secrete insulin
beta
__ cells secrete somatostatin
delta
___ is a hormone associated with energy abundance and storage of this excess energy
Insulin
Insulin causes carbohydrates to be stored as ___ in muscle and liver; excess carbs that cannot be converted to glycogen are converted to ___ and are stored in ___; insulin promotes uptake of amino acids and their conversion to ___
carbs to be stored as glycogen in muscle and liver; excess carbs that cannot be converted to glycogen are converted to fat and are stored in adipose; insulin promotes uptake of amino acids and their conversion to protein
Insulin release is stimulated by ___ (low/high) blood glucose, amino acids, beta-keto acids, glucagon, acetylcholine, intestinal hormones, beta agonists
high blood glucose
Insulin release is inhibited by ___ (low/high) blood glucose, fasting, glucagon, cortisol, catecholamines (alpha-agonists), growth hormone, somatostatin
low blood glucose
Catecolamines ___ (stimulate/inhibit) insulin release
inhibit
Plasma half-life of insulin is ___ to ___ minutes
6 to 7 minutes
Neurons are ___ to glucose
permeable
___ is the body’s key hormone controlling plasma glucose removal
insulin
Insulin is released when energy intake exceeds ___ requirements
usage
Insulin allows energy from glucose to be stored as ___, ___, and ___
glycogen, structural proteins, and fat
Insulin release begins at ___ mg/dl; max response at ___-___ mg/dl
100 mg/dl; max response at 400-600 mg/dl
Rapid rise in insulin released is matched by rapid turn-off of insulin once glucose is reduced–T/F?
True
___ is secreted by alpha cells of the islets of Langerhans when blood glucose levels fall
glucagon
Glucagon has effects that oppose the effects of ___
insulin
Glucagon ___ (increases/decreases) blood glucose concentration and can cause ___glycemia
increases blood glucose concentration and can cause hyperglycemia
Glucagon enhances ___ strength
heart
Glucagon release is stimulated by ___glycemia, beta-adrenergic ___, ___
fasting hypoglycemia, beta-adrenergic stimulation, exercise
Exercise causes release of glucagon not d/t ___glycemia, but as a response to increased circulating ___
not d/t hypoglycemia, but as a response to increased circulating amino acids
Glucagon release is stimulated by ___kinin, ___in, and ___ol
cholecystokinin, gastrin, cortisol
Surgery stimulates the release of ___
glucagon
Glucagon is inhibited by ___ (low/high) glucose levels, ___statin, ___ acids, ___ones, and ___
high glucose levels, somatostatin, free fatty acids, ketones, and insulin
Antidote for beta blocker overdose = ___
glucagon–has been used to improve cardiac isotropy to overcome a beta blocked heart; basically overpowers beta receptors
What is this?–disorder of metabolism causing excessive thirst and the production of large quantities of urine
Diabetes
What is this?–a syndrome of impaired carbohydrate, fat, and protein metabolism caused by either a lack of insulin or a decreased sensitivity of tissues to insulin
Diabetes
Type ___ diabetes is caused by a lack of insulin secretion
I
Type ___ diabetes is caused by decreased sensitivity of the tissues to insulin (insulin resistance)
II
Insulin insufficiency leads to ___glycemia from decreased cell entry, ___ (increased/decreased) gluconeogenesis, and ___ release from the liver
hyperglycemia, increased gluconeogenesis, and glucose release from the liver
Glucose is reabsorbed by the kidney until about ___ mg/dl
180
Acute symptoms of diabetes–___uria, ___dipsia, ___phagia and weight ___, CNS ___/___, visual ___
polyuria, polydipsia, polyphagia and weight loss, CNS irritability/confusion, visual disturbances
Type 1 DM is caused by destruction of ___ islet cells, resulting in loss of insulin release
destruction of beta islet cells
Type 1 DM can be caused by ___ infections or ___ disorders
viral infections or autoimmune disorders
Type 1 DM–___ plays a role in determining susceptibility of beta cells to insults
heredity
Type 2 DM is caused by greatly diminished sensitivity of target tissues to metabolic effects of ___
insulin
High levels of keto acids are NOT usually present in type ___ diabetes
2
Plasma insulin is ___ in type 2 DM
elevated–levels still insufficient for regulation, beta-cells become exhausted in some patients
Most patients with type 2 DM are ___ (80%), ___
obese–80%, sedentary
DM diagnosis–A1C >/= ___
> /= 6.5%
DM diagnosis–fasting plasma glucose (FPG) >/= ___ mg/dl
> /= 126 mg/dl
DM diagnosis–2-hr plasma glucose > ___ mg/dl during oral glucose tolerance test
> 200 mg/dl
DM diagnosis–random plasma glucose >/= ___ mg/dl in patient with symptoms of ___glycemia or ___glycemic crisis
> /= 200 mg/dl in patient with symptoms of hyperglycemia or hyperglycemic crisis
___ is commonly used to diagnose DM
Hgb A1C
___ is used to gauge how well managed a person’s diabetes is
Hgb A1C
Hgb A1C reflects average blood sugar level over approximately ___ months (RBC lifespan)
3
Normal Hgb A1C levels are between ___-___%
4-5.6%
The higher the Hgb A1C, the ___ (lower/higher) the risks of developing complications related to diabetes
higher
Consensus–BS > ___ should be treated
> 200
Plan surgery in diabetics as ___ case of the day to prevent prolonged fasting
1st
Oral hypoglycemics are held day of surgery to prevent hypoglycemia until oral intake is restarted–T/F?
True
Insulin therapy should balance adequate glucose control with the avoidance of hypoglycemia–T/F?
True
Type 1 diabetics ___ (should/should not) continue basal insulin administration to avoid ketoacidosis
should continue
Patients on insulin pumps may be managed by continuing the pump for short operations or changing over to ___
IV insulin infusions
Oral hypoglycemic agents are used as adjuncts to ___ therapy and ___ for treating Type 2 diabetics
diet therapy and exercise
Type 2 diabetics target A1C < ___% or < ___% in older adults without hypoglycemia
< 7% or < 8%
These drugs decrease hepatic glucose production, increase peripheral insulin uptake; example = metformin (glucophage)
Biguanides
Biguanides can cause lactic ___ in surgical patients, especially patients with liver/kidney disease and/or CHF; biguanides can be used to treat ___ disease
lactic acidosis in surgical patients; can be used to treat polycystic ovarian disease
___ have a hypoglycemia risk because they increase insulin secretion from the pancreas; examples = glimepiride, glipizide, glyburide
sulfonylureas
___ are similar to sulfonylureas in that they increase insulin production and thus carry a hypoglycemia risk; example = repaglinide (prancing)
Meglitinides
Thiazolidinediones (i.e.: tazone, pioglitazone) decrease glucose production in liver, decrease insulin resistance; there was a 2010 CHF black box warning that has been lifted; if patient has class III or IV CHF, probably shouldn’t give it–T/F?
True
Alpha-glucosidase inhibitors (i.e.: acarbose) slow ___ and ___ of carbs from GI tract; these should be avoided in ___ diseases
slow digestion and absorption of carbs from GI tract; these should be avoided in intestinal diseases
___ insulin is most often used for IV
regular insulin
Long-acting insulin should be ___% day of surgery
50%
Hold ___-acting and ___-acting insulin day of surgery
short-acting and regular-acting
Greatest risk with insulin given day of surgery is ___
hypoglycemia
___ is added to some insulins to prolong their effect
Protamine
Must be cautious when giving ___ to reverse heparin; monitor patient for ___ reaction
must be cautious when giving protamine to reverse heparin; monitor patient for hypersensitivity reaction
DKA occurs in type ___ diabetics with ___ insulin levels
occurs in type 1 diabetics with profoundly low insulin levels
Primary features of DKA = ___hydration, ___osis, ___ depletion
dehydration, acidosis, electrolyte depletion
In DKA, blood glucose ___ (increases/decreases) without effective insulin, leading to osmotic ___ and lyte ___
blood glucose increases without effective insulin, leading to osmotic diuresis and lyte losses
DKA–dehydration up to ___-___ L
4-6L
DKA–loss of up to ___% body K+
10%
Symptoms of DKA–___/___; ___uria; ___dipsia; ___phagia; ___exia; ___ changes; ___ breathing; ___ halitosis
nausea/vomiting; polyuria; polydipsia; polyphagia; anorexia; orthostatic changes; Kussmaul breathing; acetone halitosis
LOC in DKA is related to patient’s ___, not acidosis
osmolality
Treatment of DKA = massive ___, ___ replacement, ___ therapy
massive fluid resuscitation, electrolyte replacement, insulin therapy
Patients with DKA will often present with severe ___kalemia
hyperkalemia
Nonketotic hyperosmolar state occurs in type ___ diabetics; same precipitating events as DKA with very high blood ___
type 2; very high blood glucose
Primary features of nonketotic hyperosmolar state–severe ___glycemia; ___hydration; severe ___osmolar state (Na down 1.6/100 glucose); and lack of ___
severe hyperglycemia; dehydration; severe hyperosmolar state; and lack of ketoacidosis
Symptoms of nonketotic hyperosmolar state–___osis from ___viscosity; neuro signs–___, ___, ___
thrombosis from hyper viscosity; neuro signs–confusion, seizures, coma
Treatment of nonketotic hyperosmolar state = ___ resuscitation; add ___ to IVF when BG ~250 to avoid precipitous drop and cerebral edema; K+, phosphate, insulin if needed
fluid resuscitation; add glucose to IVF
Hypoglycemia has profound effects on ___
CNS–confusion, convulsions, coma
Early response to hypoglycemia–liver ___ breakdown
liver glycogen breakdown
Late response to hypoglycemia–___ stimulation, ___ release
sympathetic stimulation, epi release
Very late response to hypoglycemia–___ and ___ secreted
growth hormone and cortisol secreted
___ = beta cell adenoma
insulinoma
Insulin shock = coma under ___ mg/dl
20 mg/dl
Treatment of insulin shock = ___
glucose, glucagon, epi
Hypoglycemic shock develops in range of ___-___ mg/dl
20-50 mg/dl
Hypoglycemic shock–progressive nervous irritability leads to ___, ___, and ___
fainting, seizures, and coma
Hypoglycemic shock–brain uses glucose only if available, but can use ___ with difficulty in times of stress
fats/ketones
Treat hypoglycemic shock with ___ and infusion of ___
D50 and infusion of D5
Prolonged hypoglycemia leads to brain cell death and apoptosis–T/F?
True
Thyroid gland regulates ___
metabolic rate
Thyroid blood supply comes from ___ and ___ thyroid arteries
superior and inferior
The thyroid is a very ___ organ
vascular
Thyroid is ___ shaped
butterfly
Thyroid is one of the ___ endocrine glands
largest
Thyroid consists of two ___ and an ___
two lobes and an isthmus–isthmus connects the R and L thyroid glands/lobes
Thyroid produces what (3) thyroid hormones:
- Thyroxine (T4)
- Triiodothyronine (T3)
- Reverse T3 (rT3)–inactive
1 mg of iodine is required each week to form normal amounts of thyroid hormone–T/F?
True
___ is absorbed from our diets and then converted to iodide before it is used by the thyroid
Iodine
When adequate iodine is not available, the thyroid ___ produce the hormones
cannot
___ is the functional unit of the thyroid
follicle
___ is where thyroid hormone is stored; stores enough thyroid hormone to last ___-___ months
colloid; stores enough thyroid hormone to last 2-3 months
Since the colloid stores enough thyroid hormone to last 2-3 months, if you had a complete loss of thyroid hormone production, the physiologic effects wouldn’t be seen for several months–T/F?
True
TSH is secreted from the ___ pituitary and attaches itself to the ___ of the follicle
TSH is secreted from the anterior pituitary; attaches itself to the outside of the follicle
___ is very important for the thyroid to create its hormones and convert ___ (active) to ___ (inactive)
Iodine; convert T4 (active) to T3 (inactive)
T4 = ___
thyroxine
T3 = ___
triiodothyronine
___ and ___ are the most important thyroid hormones for metabolic control
T4 and T3
The secretion of T4 from the thyroid is ___-___ mcg/day
80-100 mcg/day
The thyroid secretes ___% thyroxine (T4) and ___% triiodothyronine (T3)
93% T4, 7% T3
Nearly all T4 is deiodinated to T3 in the tissues–T/F?
True
T3 is ___x more potent than T4 but is more ___ and cleared more ___ (less protein bound)
T3 is 4x more potent than T4 but is more scarce and cleared more rapidly (less protein bound)
The thyroid directly secretes ___, which is converted to ___
secretes T4, which is converted to T3
___ mostly acts as a hormone precursor or vehicle for ___
T4 mostly acts as a hormone precursor or vehicle for T3
Most of the thyroid hormone effects come from ___
T3
Synthroid = synthetic ___
T4
___ is heavily protein-bound; 99% bound to plasma proteins (i.e.: albumin); has a very ___ half-life
T4; has a very long half-life
___ has a much shorter half-life and controls most of the effects of the thyroid hormones
T3
TRH is released by the ___
hypothalamus
TRH causes release of ___ by the anterior pituitary
thyroid-stimulating hormone
TSH causes release of ___ hormones (both ___ and ___) from the thyroid gland
thyroid hormones (both T3 and T4)
Only ___ thyroid hormone is active
free
Over ___% of thyroid hormone is bound to protein–thyroid binding globulin (TBG) or lesser extent albumin
99%
___ is more metabolically active
T3
Physiologic effects of the thyroid come from ___
T3
Because of the high amount of protein binding and slow release into cells, T4 half-life is ___-___ days, T3 half-life is ~___ hours
T4 half-life is 6-7 days, T3 half-life is ~24 hours
It is likely that all cells in the body are targets for thyroid hormones–T/F?
True
Thyroid hormone net effect is a widespread increase in ___ activity, ___ production, and ___ consumption in nearly all cells
increase in metabolic activity, heat production, and oxygen consumption
Thyroid hormone causes vaso___ from ___ (increased/decreased) cellular O2 consumption; ___ (increases/decreases) blood flow to most tissues
causes vasodilation from increased cellular O2 consumption; increases blood flow to most tissues
Muscles can become weak when thyroid hormone is excessive d/t protein catabolism–T/F
True
___ is a condition where the thyroid cannot make adequate TH; it is the most common thyroid disorder; women>men
Hypothyroidism
Primary hypothyroidism–___% of most cases
95%
Primary hypothyroidism–___ TSH, yet T3 and T4 are ___ because of problems with the thyroid gland
elevated TSH, yet T3 and T4 are not produced because of problems with the thyroid gland
Primary hypothyroidism is most commonly due to ___; most often occurs in ___; can be associated with other auto-immune disorders
most commonly due to autoimmune Hashimoto’s thyroiditis; most often occurs in middle-aged females
___ inhibits the release of TH and can cause hypothyroid
Lithium
Secondary hypothyroidism–___% of cases; inadequate T3, T4 due to ___ not being released from the pituitary
5% of cases; inadequate T3 and T4 due to TSH not being released from the pituitary
Tertiary hypothyroidism–
< 5% of cases; inadequate T3, T4 due to thyrotropin releasing hormone (TRH) from hypothalamus
Hypothyroidism that occurs in infancy leads to ___ and ___ (cretinism)
mental retardation and growth deficits (cretinism)
The most severe form of hypothyroidism is ___
myxedema coma
Myxedma coma is triggered by ___, ___, exposure to ___, ___
illness, infection, exposure to cold, medicines
Symptoms of myxedema coma include ___, ___ (increased/decreased) breathing, ___ (increased/decreased) blood sugar, ___ (increased/decreased) blood pressure, and ___ (increased/decreased) temperature
coma, decreased breathing, decreased blood sugar, decreased blood pressure, and decreased temperature
___ is the standard test for thyroid gland function
Serum T4 assay
Total T4 is ___ in 90% of people with hyperthyroidism
elevated
Total T4 is ___ in 85% of people with hypothyroidism
low
Blood levels of TSH are ___ in primary hypothyroidism
high
Treatment of hypothyroid centers on replacing ___ until thyroid hormone levels normalize
replacing the thyroid hormone that is lacking until thyroid hormone levels normalize
___ is the most commonly used medicine to treat hypothyroid
Levothyroxine (Synthroid)–synthetic T4
Elective surgery should be postponed until ___ state is achieved, but this is not always done
euthyroid
Hypothyroid and anesthesia–be aware of the ___ possibility
“crash on induction”
Want to give ___ for induction for patients with hypothyroid
sympathomimetics
___ is frequently used on induction for patients with hypothyroid; helps prevent drops in BP
Ketamine
___ agents not recommended in patients with hypothyroidism d/t the sensitivity of the myocardium to depression
Volatile
___onium/___onium have vagolytic/sympathomimetic effects
Pancuronium/rocuronium
___ is a condition of thyroid gland overactivity
Hyperthyroidism
___ is inflammation of the thyroid which causes release of excessive hormone but not increased production
Thyroiditis
___ is an oversupply of thyroid hormones on peripheral tissues (another name for hyperthyroidism)
Thyrotoxicosis
Staring gaze in hyperthyroidism = ___
exophthalmos
Most common cause of hyperthyroidism is ___ (60-90% of cases), which is an autoimmune disease
Grave’s disease
Grave’s disease–autoantibodies activate the ___ receptor, causes mutlinodular ___
TSH, causes multi nodular goiter
Treatment of hyperthyroidism involves initial temporary use of ___ and possibly late use of permanent ___ or ___ therapy
initial temporary use of suppressive medicines and possibly late use of permanent surgical or radioisotope therapy
Two antithyroid drugs that inhibit production of TH–___ and ___
methimazole and propylthiouracil (PTU)
Antithyroid drugs inhibit ___ of thyroglobulin and prevent conversion of ___ to ___
inhibit iodination of thyroglobulin and prevent conversion of T4 to T3
Propranolol for hyperthyroidism–L-isomer causes ___
beta blockade–treats tachycardia, tremor, palpitations, anxiety, and heat intolerance
Propranolol for hyperthyroidism–D-isomer inhibits the conversion of ___ to ___
T4 to T3
Radioactive iodine for hyperthyroidism–one time dose in ___ form, results in ___ of thyroid tissue
one time dose in pill form, results in destruction of thyroid tissue
Surgery for hyperthyroidism–___ or ___ thyroidectomy
partial or total thyroidectomy
Surgery for hyperthyroidism is used extensively–T/F? Why?
False–is NOT used extensively in the absence of cancer as meds are effective and there are risks of removing parathyroids or recurrent laryngeal nerve
___ = extreme form of hyperthyroidism
Thyroid storm
Thyroid storm occurs within ___-___ hours postop
6-18 hours
80% of patients who experience thyroid storm are not suspected of having ___
thyroid problems
S/S of thyroid storm–___thermia, ___cardia, ___rhythmias, ___, ___
hyperthermia, tachycardia, dysrhythmias, CHF, shock
Symptoms of thyroid storm may resemble ___, ___, ___
MH, pheochromocytoma, neuroleptic malignant syndrome
Because thyroid storm may resemble many other things, it is important to obtain a ___ diagnosis
differential
i.e.: MH usually occurs intraoperatively with elevated CO2; thyroid storm typically occurs postoperatively
Treatment of hyperthyroidism before surgery–sodium iodide and propranolol lead to euthyroidism in about ___ days
10 days
Treatment of hyperthyroidism before surgery–antithyroid drugs ___-___ weeks before surgery (i.e.: methimazole, PTU)
6-8 weeks
Patients with hyperthyroidism–check airway for goiter, wheezing, obstruction; goiter can be ___/___sternal and might not be so obvious; may have to do an ___ intubation on these patients if they have symptoms of airway compromise
goiter can be sub/retrosternal and might not be so obvious; may have to do an awake fiberoptic intubation
Goiter means ___
enlargement
Goiter results from chronic stimulation by ___
TSH
In an emergency, administer antithyroid drugs–sodium ___; ___–blocks peripheral conversion of T4 to T3, making rT3 instead; and ___
sodium iodide; cortisol; PTU
Avoid ___ [volatile agent] and ___ [ACLS drug] in hyperthyroid patients
halothane and atropine
Neuro monitoring with him tube = wires placed at the level of the ___ to monitor the ___ and ___ during thyroidectomy
wires placed at the level of the vocal cords to monitor the RLN and SLN during thyroidectomy
Unilateral RLN damage = ___
hoarseness
Bilateral RLN damage = ___, ___, ___
aphonia, stridor, aspiration
SLN damage = ___ voice in upper registers
abnormal
Hematoma/bleed during thyroidectomy = airway ___ requiring decompression and rapid ___ before airway compromise
airway emergency requiring decompression and rapid intubation before airway compromise
___calcemia results from inadvertent removal of the parathyroid glands; signs = ___ness, ___ny, and ___spasm 24-72 hours later
Hypocalcemia; signs = weakness, tetany, and laryngospasm 24-72 hours later
Hypocalcemia can end with ___ collapse
CV collapse
___ = tracheal softening, causes airway collapse with inspiration
tracheomalacia
Why is calcium important?–___ conduction, ___ formation, ___ function, blood ___, ___ and ___ function, capillary ___, cell ___ and ___, ___transmitter action
nerve conduction, bone formation, muscle function, blood coagulation, cerebral and cardiac function, capillary permeability, cell growth and division, neurotransmitter action
Body contains ___-___kg of calcium
1-2 kg
___% of calcium is in the skeleton, ___% is in the plasma, and ___% is in the ECF, ___% in cells
98% in skeleton
- 03% in plasma
- 1% in ECF
1% in cells
Plasma calcium–___% ionized, active form
50%
Ionized calcium is most important for calcium functions on ___, the ___ system, and ___ formation
the heart, the nervous system, and bone formation
___% of calcium is protein bound, primarily bound to albumin
41%
___calcemia = nervous system excitement
hypocalcemia
Signs of hypocalcemia = ___ny, ___ures, ___ QT interval
tetany, seizures, longer QT interval
Hypocalcemia–inflate BP cuff and hand spasms = ___ sign
Trousseau’s sign
Hypocalcemia–tapping facial nerve leads to twitching = ___ sign
Chvostek’s sign
Hypercalcemia–chief manifestation = skeletal muscle ___
weakness
Other signs of hypercalcemia = nervous system ___; ___ QT; ___ PR interval; ___ [think GI]; ___xia
nervous system depression; short QT; long PR interval; constipation; anorexia
Treatment of hypercalcemia–maintain ___, ___ate, administer ___ (antibiotic) in severe cases
maintain UOP, hydrate, administer mithramycin (antibiotic) in severe cases
Body contains ___ kg of phosphorus
1
Phosphorus–___% skeletal, ___% muscle/tissue, ___% ECF
85% skeletal, 15% muscle/tissue, 1% ECF
Phosphorus levels fluctuate significantly more than Ca levels because phosphorus moves between ECF and ___ as well as between ECF and ___
between ECF and bone as well as between ECF and ICF
Phosphorus is easily absorbed via the ___ tract
GI
Major control site of phosphorus is the ___
kidney–urinary excretion balances GI intake
PTH ___ (increases/decreases) urinary excretion of phosphorus
increases
GI absorption of phosphorus is increased by ___
1,25 D3
1,25 D3 = ___
active metabolite of vitamin D
Parathyroid consists of ___ glands
4
Parathyroid glands contain mainly ___ cells and ___ cells
chief cells and oxyphil cells
Chief cells secrete ___ hormone
parathyroid hormone
Synthesis and secretion of parathyroid hormone is related to ___ concentrations in the blood
calcium
Parathyroid glands can become enlarged from prolonged ___, ___nancy, ___tation
prolonged stimulation, pregnancy, lactation
Decreases in calcium concentration in the ECF ___ (increases/decreases) secretion of PTH
increases
Increases in calcium concentration in the ECF ___ (increases/decreases) secretion of PTH
decreases
When PTH is secreted, it ___ (increases/decreases) bone reabsorption to mobilize calcium and phosphate–resorption = process by which osteoclasts break down bone and release calcium from bone fluid to blood
increases
PTH ___ (increases/decreases) reabsorption of Ca in the kidney’s distal tubules
increases
PTH ___ (increases/decreases) reabsorption of phosphate in the renal tubules
decreases
PTH ___ (increases/decreases) the production of 1,25 D3 which ___ (enhances/inhibits) intestinal Ca absorption
PTH increases the production of 1,25 D3 which enhances intestinal Ca absorption
Major stimulus for PTH is ___ serum Ca level
low
Increased PTH results in serum: ___ calcium, ___ phosphate
increased calcium, decreased phosphate
Increased PTH results in urine: ___ calcium, ___ phosphate
decreased calcium, increased phosphate
PTH increases the ___ of phosphate, potassium, and sodium by increasing the ___ of calcium, magnesium, and hydrogen
excretion, reabsorption
Excretion/reabsorption largely takes place in the distal tubules/collecting ducts–T/F?
True
___ is produced in the parafollicular (clear or C cells) of the thyroid; in general, it has the opposite effect of parathyroid hormone
Calcitonin
Calcitonin ___ (increases/decreases) calcium by ___ bone resorption and ___ urinary excretion of calcium
calcitonin decreases calcium by inhibiting bone resorption and increasing urinary excretion of calcium
Calcitonin–serum calcium and phosphate are ___
decreased
Calcitonin–urine calcium and phosphate are ___
increased (d/t increased excretion)
Secretion of calcitonin is controlled by serum ___ level
calcium
___ (increased/decreased) calcium leads to increased calcitonin secretion
increased
___ has a potent effect to increase calcium absorption from the intestinal tract
Vitamin D
Vitamin D has important effects on both bone ___ and bone ___
bone deposition and bone absorption
Vitamin D is not an ___ substance
active
Vitamin D must be converted to its active product ___
1,25 D3 (dihydroxycholecalciferol)
Vitamin D3 is formed in the ___ by exposure to ___
formed in the skin by exposure to sunlight
Vitamin D3 is converted to 1,25 D3 by the ___
liver
GI absorption of calcium is ___ (increased/decreased) by vitamin D
increased
Urinary excretion of calcium is ___ (increased/decreased) by PTH and ___ (increased/decreased) by calcitonin
decreased by PTH and increased by calcitonin
Bone resorption of calcium is ___ (increased/decreased) by PTH and ___ (increased/decreased) by calcitonin
increased by PTH and decreased by calcitonin
Hypoparathyroidism is usually a result of damage to the gland during ___
thyroid surgery
Hypoparathyroidism–calcium levels fall below normal in ___-___ hours, which results in: ___ny, muscle ___, ___ seizures, CV ___
24-72 hours, which results in: tetany, muscle cramps, grand mal seizures, CV collapse
Treatment of hypoparathyroidism = high ___ and ___ intake
calcium and vitamin D intake
PTH could be used to treat hypoparathyroidism, but it is ___ and has a ___ half-life
expensive and has a short half-life
Occasionally, ___ is necessary for treatment of hypoparathyroidism
Vitamin D3 (1/25-D3)
___magnesemia can cause hypocalcemia that is resistant to calcium–so treat first with ___
Hypomagnesemia–so treat first with magnesium
Magnesium suppresses the release of ___
PTH
Primary hyperparathyroidism = inappropriate hyper secretion of ___, resulting in hypercalcemia
PTH
Primary hyperparathyroidism results in ___calcemia, ___calciuria, ___phosphatemia
hypercalcemia, hypercalciuria, hypophosphatemia
Primary hyperparathyroidism (too much calcium) = ___ QT interval, ___ cardiac relaxation
shortens QT interval, depresses cardiac relaxation
Primary hyperparathyroidism causes ___ formation as calcium mobilized from bone must eventually be excreted by kidneys
kidney stone formation
Most common cause of hyperparathyroidism is parathyroid ___ or ___
parathyroid hyperplasia or parathyroid tumor
___ may stimulate the parathyroids
Pregnancy
Secondary hyperparathyroidism results from hypersecretion of ___ in response to a ___calcemic stress–i.e.: vitamin D deficiency, chronic renal disease
PTH in response to a hypocalcemia stress
Secondary hyperparathyroidism results in ___, d/t inadequate mineralization of the bones
osteomalacia
Vitamin D deficiency results from inadequate ___
dietary intake–often d/t fat malabsorption syndrome
Vitamin D deficiency can result from inadequate ___
sunlight
Vitamin D deficiency–___ (increased/decreased) absorption of calcium and phosphate, ___ (increased/decreased) serum calcium and phosphate, ___ (increased/decreased) PTH and ___ (increased/decreased) bone resorption
decreased absorption of calcium and phosphate, decreased serum calcium and phosphate, increased PTH and increased bone resorption
Vitamin D deficiency results in ___ in adults
osteomalacia
Vitamin D deficiency results in ___ in children
rickets–bones fail to mineralize, epiphyses fail to fuse, epiphyseal plates widen and bowing and fractures occur
1 gm of calcium chloride = ___ gm of calcium gluconate
3 gm
Calcium is indicated for treatment of ___kalemia induced EKG changes because of its cell membrane stabilizing effects
hyperkalemia
Calcium is indicated in patients with ___ associated with either calcium channel blockers or beta adrenergic blockers
hypotension
Calcium is indicated in cases of ___ toxicity, as may occur in parturients being treated for preeclampsia
magnesium
Calcium is contraindicated in patients with ___ toxicity, as it may cause lethal arrhythmias
digoxin
