Houseman handbook_Endocrinology

Question 1

DM insulin

Answer 1

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Question 2

DM periop

Answer 2

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Question 3

DKA

Answer 3

Criteria: glc >14, ABG pH <7.3, HCO3 <15, moderate ketonuria/ ketonemia

Ix:

• Urine x glc, ketone, BAHA
• Bld x CBCd/c RFT (urea/Cr/Na K) CaPO4 Mg AG ABG RG ketone BAHA
• +- CXR/ ECG/ septic workup/ urine and serum osm/ PT APTT
• Monitor BP/P RR conscious level UO CVT Q1H, Obs q2H
• NGT if unconscious/ vomiting
• Foley to BSB, chart I/O
• Monitor RFT AG RG till RG <14 +- repeat ABG

Tx

• 1-2L NS over 1-2H, when Na >150 use hypotonic NS (Fluid in 12H NOT exceed 10% BW)
• Regular human insulin 0.15U/kg as bolus, then infusion 0.1U/kg/H (aim dec glc 3-4mmol/H, double insulin dose prn)
• K 10-20mmol/H (aim K 4-5; K>5.5: stop K, K>5: 8mmol/H, K <4: 30mmol/H, K<3: 40mmol/H)
• NaHCO3: pH <6.9 100mmol NaHCO3 in 2H, 6-9-7.0 50mmol NahCO3 in 1H), repeat ABG after infusion after 2H
• BG <14: IVF to D5, insulin infusion to 0.05-0.1U/kg/H / 5-10U SC Q4H (maintain bgl 8-12mmol/L), dec monitoring to q2-4H
• AG normal/ normal diet: maintenance insulin

Question 4

HHS

Answer 4

Criteria: glc >33mmol/L, ABG pH >7.3, HCO3 >15, effective serum osm (2x Na +glc)>320mOsm/kg H2O, mild ketonuria/ ketonemia +- change in metal state

Tx:

• ~DKA
• Fluid!!! (hypotonic NS if Na high)
• Caution for heart failure
• Monitor bld urea
• Insulin requirement less, but look out for rapid fall in glc and overshot hypoglc

Question 5

Hypoglc

Answer 5

• D50 40ml stat + D10 drip
• Glucagon 1mg IMi (avoid in pheo) / Oral glc (ensure airway)
• Monitor bld glc + Hstix Q1-2H
• Dped on LRFT and insulin/ drugs

Ix

1. Prolonged OGTT (reactive hypoglc, limited use)
   - Overnight fast> 75g anhydrous glc PO> plasma glc and insulin Q1H for 5H + when symptomatic
2. Prolonged fasting (tight monitoring)
   - Fast 72H, vigurous exercise 20mins if no hypoglc)> Hstix Q4H + when symptomatic, Bld x glc insulin Cpeptide at 0, 24, 48, 72H + swhen symptomatic/ Hstix <3 > termniate test if Hstix <3

Question 6

Thyroid storm

Answer 6

Close monitoring: CVP, swan ganz, cardiac monitoring, ICU

1. Hyperthermia
   - paracetamol, physical cooling
2. Dehydration
   - IVF: 2-4L/D i.e. IVF Q3-6H
   - IV glucose, thiamine
3. Supportive (Cx)
   - O2, digoxin/diuretics if CHF/AF +- inotrope
4. Antithyroid
   - PTU 150-200mg Q4-6H PO/ via NG tube
   - Hydrocortisone 200mg stat IV then 100mg Q6-8H
   - BB (C/I in CHF/Cm/asthma/COAD): Propanolol 40-80mg Q4-6H PO/NG or Propanolol 0.5-1mg IV over 10mins every several hours
5. Block hormone 1H later
   - Lugol soln 10 drops q8H (1 drop= 6.25mg iodide/iodine)
   - SSKI 5 drops PO q6H
   - NaI continuous IV 0.5-1g Q12H
   - Oragrafin/ ipodate PO 1-3g/D

If antithyroid contraindicated:

• Li2CO3 250mg Q6H to acheive Li level 0.6-1.0mmol/L
• Plasmapheresis/ charcoal hemoperfusion

Question 7

Myxedema coma

Answer 7

Treat precipitating cause
Fluid and e, glc (D10)

1. Hypothermia: maintain body temp
2. Hydration
   - NS IV 200-300mL/H +- vasopressor
3. Thyroid replacement
   - T4 200-500mcg PO stat then 100-200mcg PO / T3 20-50mcg stat, then 20mcg Q8H PO
   - T3 IV 5-20mcg daily if oral route not possible
   - Hydrocortisone 100mg Q6H IV

Question 8

Pheochromocytoma

Answer 8

Triad of headache sweating tachycardia
Secondary HTN (young/severe/resistant, labile BP, adrenal incidentaloma)

Ix:

• urine catecholamine, fractionated metanephrine, normetanephrine
• imaging for pre-op localization and staging
• A-block FIRST then B-block: phenoxybenzamine, prazosin, doxazosin, terazosin

Question 9

Addisonian crisis

Answer 9

Ix

• bld x RFT e- RG spot cortisol +- ACTH
• normal dose SST (250mcg) if not already in stress / low dose SST (1mcg) if secondary hypocortisolism suspected
• causes

Tx (clinical suspicion)

• Hydrocortisone IV 100mg stat, then Q6H (IMI/ continuous IV infusion 200mg QD if no improvement)
• +- 9a-fludrocortisone 0.05-0.2mg QD PO, titrate to normalize K and BP
• e-
• IVF 4L at 500-1000mL/H, then 200-300mL/H, watch out fluid overload
• Dexamethasone IV 4mg Q12H (not interfere cortisol assay)

Steroid cover for surg/ trauma

• Indication:
  1. supraphysiological dose of glucocorticoid (>P7.4 QD for >2W in past year)
  2. patient currently on steroid (regardless of dose)
  3. Adrenal/ pit insufficiency
• Replacement in major surg
  > Hydrocortisone 100mg IV on call to OT
  > Hydrocortisone 50mg IV recovery room , then 50mg IV Q6H + K supplement for 24H / cont IV infusion of 200mg hydrocortisone Q24H
  > Post-op uncomplicated: Hydrocortisone IV 25mg Q6H on D2, then taper to maintenance in D3-4
  > Post-op complicated (sepsis, hypotension): Hydrocortisone IV 100mg Q6H (or 200mg IV infusion QD)
• Replacement in minor surg
  > Hydrocortisone IV 100mg once, do not interrupt maintenance

Question 10

Acute post-op DI

Answer 10

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Question 11

Pit apoplexy

Answer 11

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