Metabolic II Flashcards
cushings disease, specifically cushings syndrome is d/t?
pituitary secretion of excessive ACTH
s/sx of cushings syndrome
- Obesity/OSA (moon face and buffalo hump)
- HTN with volume overload
- electrolyte imbalances
- glucose intolerance
- GERD
- Myopathy/weakness/bruising
- infections/poor wound healing
Anesthesia considerations with Cushings
- will have htn
- normalize intravascular volume with diuresis (spirolactone)
- correct electrolytes and blood glucose
- consider etomidate
- Obesity/OSA will have issues with airway, IV access and positioning
why do we consider etomidate with cushings syndrome?
it inhibits steroid synthesis
primary adrenal insuffciency
destruction of adrenal gland
what is secondary adrenal insufficiency
anterior pituitary fails to secrete sufficient ACTH
what are some causes of primary/secondary adrenal insufficiency
autoimmune adrenalitis
TB
tumor
surgery
HIV
pituitary radiation
tertiary adrenal insufficiency
process that interfere with ACTH release
- exogenous high dose glucocorticoid therapy
- prednisone > 20 mg/day > 3 weeks
what is the average basal adrenal cortisol secretion per day?
30 mg/day
the stress of surgery, trauma, and infection can increase adrenal output of glucocorticoids up to ___________ mg/day
300
what are the s/sx of adrenal insufficency
- fatigue
- loss of appetite
- weight loss
- hypoglycemia
- hyponatremia
- hyperkalemia
- orthostatic hypotension
- hyperpigmentation
anesthesia considerations with adrenal insuffiency
- determine electrolyte levels, and glucose and manage
- myopathies –> conservative approach to NMB & respiratory insufficiency postop
- refractory to vasopressor and fluid therapy
- AVOID etomidate
- possible corticosteroid supplementation
when would you consider corticosteroid supplemenation intraoperatively in patient with adrenal insufficiency
if pt having major procedure and takes > 20 mg/day of prednisone or its equivalent
T/F: pts with adrenal insufficiency should discontinue glucocorticoid/mineralcorticoid drug therapy day of surgery
false; should continue
what is the risk of taking high dose steroid supplementation
adrenal insufficiency risk remains up to 1 year after cessation
unable to increase endogenous cortisol to respond to surgical stress
stress dose corticosteroid administration for minor procedures (adrenal insuff)
hydrocortisone 25 mg or methylprednisolone 5 mg DOS
stress dose corticosteroid administration for moderate procedures (adrenal insuff)
hydrocortisone 50-75 mg or methylprednisolone 10-15 mg DOS then taper over 1-2 days
stress dose corticosteroid administration for major procedure (adrenal insuff)
hydrocortisone 100-150 mg or Methylprednisolone 20-30 mg DOS then taper over 1-2 days
patient with pheochromocytoma has surgery scheduled; what should be prescribed to them outpatient and started 10-14 days prior to surgery date?
alpha blockade (phenobenzamine)
for patient with pheochromocytoma, once BP is undercontrol with alpha blockade, then you initiate _______________________
beta blocker
T/F: pts with pheochromocytoma should take all BP meds day of surgery
true
What should you expect intraoperatively for pt with pheochromocytoma
- aggressive hydration for euvolemia
- major hemodynamic changes: need Aline, vasoactive meds, and plan for postop care
what hormones come from posterior pituitary gland
oxytocin, ADH
what hormones come from anterior pituitary gland
TSH
ACTH
FSH
LH
prolactin
GH
endorphins
abnormal fx of the _____________ may render the inability to appropriately respond in periods of stress (surgery) and/or critical illness
adrenal cortex
_________________ results from excess growth hormone, resulting in overgrowth of skin, connective tissue, cartilage, bone, and viscera
acromegaly
s/sx of acromegaly
- airway abnorm d/t overgrowth of pharyngeal, laryngeal, epiglottic tissues
- OSA
- V/Q mismatch d/t visceromeg
- HTN, CAD, valvular disease, HF
- DM
- arthralgia
- fractures common
pt presents with acromegaly, you should anticipate you will need a ____________ ETT
smaller; d/t overgrowth of airway tissues
SIADH dx
elevated ADH with hyponatremia, and hypo-osmolality with concentrated urine in euvolemic state
s/sx SIADH
headache
lethargy
disorientation
hallucinations
N/V
Seizures
coma
perianesthesia management of SIADH - due to chronic asymptomatic hyponatremia
water restriction and diuresis
how would you correct acute severe hyponatremia (<120) in someone with SIADH
3% NS + lasix
slow IV correction
Vasopressin-3-receptor antagonist (Tolvaptan)
why does hyponatremia (W/ SIADH) complicat anesthesia management?
potentials NMB
delays emergence
increases delirium
fluid shifts
Neurogenic DI
insufficent production of ADH
nephrogenic DI
inadequate response to ADH by target cells in the kidney
s/sx of DI
polyuria
polydipsia
alteration in mental status
arrhythmias (Na > 160)
higher serum osm with low urine osm
perianesthesia management of DI
correct free water deficit:
1. drink water if thirst mech intact
2. IV hypotonic saline (D5W)
3. DDAVP
4. off label meds
5. monitor Na and volume status
what are some off label medications for DI tx
carbamazepine
thiazide diuretics
NSAIDs
_____________ can occur with rapid Na correction in patients with chronic hypernatremia
cerebral edema
T/F: elective procedures should be postponed in pt with DI d/t hypernatremia
true
carcinoid tumors secrete
serotinin
histamine
kinins
substance B
prostaglandins
kallikrein
s/sx of carcinoid tumor
- episodes of flushing
- diarrhea
- tachycardia
- bronchospaz
- increased serotonin –> +inotropy/chronotropy d/t release of NE –> CAD and HF
anesthesia implications with carcinoid tumor
avoid carcinoid crisis through:
1. manipulation of tumor
2. chemical stimulation
3. tumor necrosis d/t induction of anesthesia and surgical stress
how do you manage pt with carcinoid tumor intraop?
octreodtide 100 mcg to suppress release of mediators
normal weight BMI
20-24.9
overweight BMI
25-29.9
obese BMI
30-34.9
severely obese BMI
35-39.9
morbidly obese BMI
> /= 40
super (morbidly) obese BMI
> /= 50
what are the pulmonary/airway anesthesia implications with obese pt
- reduced compliance of lungs and chest wall
- increased incidence of OSA
- obesity hypoventilation syndrome
- high risk of difficult airway, difficult mask ventilation
obesity hypoventilation syndrome: daytime hypercapnea + OSA –> ___________ and _____________
HTN; R-sided HF
Cardiac anesthesia implications with obese pt
- s/sx of cardiac disease
- HTN + LVH + HF
- dysrrhythmias are common
GI/metabolic/endocrine anesthesia implications with obese pt
- increased gastric residual volume, abdominal pressure, Hiatial hernia
- increased risk of fatty liver dz
- metabolic syndrome + DM
- increased subclinicl hypothyroidism
in an obese pt what can you use to stratify risk for that patient
obesity surgery mortality risk
perianesthesia management with obese pt
- consider BP cuff size/ABP
- OR table weight limitations
- IV access may be difficult
- planning for difficult intubation and extubation
- potential for aspiration
- postoperative SpO2 and CPAP
- possibly post op ICU