Principles-Management of Endocrine Disorders Flashcards by hassan gonzales

The main anesthetic concern with somoeone with thyroid is related to what system

cardiovascular

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Thyroid hormone causes what principle effect on the CV receptors

Increases its number thereby effecting the tissues reponses to sympathetic stimuli

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In primary hyperthyroidism, what changes would you expect for t3,t4, and tsh

t4 increased
t3 increased
tsh decreased

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In secondary hyperthyroidism, what changes would you expect for t3, t4, and tsh

t4 increased
t3 increased
tsh increased

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In primary hypothyrodism, what changes would you expect for t3, t4, and tsh

t4 decreased
t3 decreased
tsh increased

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In secondary hypothyroidsm, what changes would you expect for t3, t4, and tsh

t3 decreased
t4 decreased
tsh decreased

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What is the most common cause of hyperthyroidism

Graves disease (a multinodular diffuse goiter)

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What are the clinical manifestations of hyperthyroidism

Weight loss
diarrhea
skeletal muscle weakness
warm/moist skin
heat intoloerance
exophthalmos
nervousness

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What are the CV manifestations of hyperthyroidism

Increased left ventricular contractility
Increased ejection fraction
Tachycardia
Hypertension

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Ideally, what state should the a hyperthyroid patient be in prior to surgery

Euthyroid

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What four medications are used to treat hyperthyroidism

Beta-adrenergic antagonists
Iodine
Methimazole
Propylthiouracil

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A SYMPTOMATIC hyperthyroid patient requiring emergency surgery should receive

beta blockers to achieve a HR < 90

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Should hyperthroid patients continue therapy up to the morning of surgery

Yes

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Are Euthyroid patients considered normal for anesthesia

yes

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What is the main goal for treating symptomatic hyperthyroid patients

Prevent exagerrated sympathetic response

-avoid medications that increase SNS discharge

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Name a NDMB that should be avoided in hyperthyroid patients

pancuronium

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Name an induction agent that should be avoided in symptomatic hyperthyroid patients

Ketamine

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Name a inhaled induction agent that should be avoided in the symptomatic hyperthyroid patient

Rapid titration of desflurane

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The incidence of what neuromuscular disease is increased with hyperthyroid patients

Myasthenia Gravis

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Treating hypotension for symptomatic hyperthyroidism should be done with what

Direct-acting vasopressors

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Name commonly used Direct-acting vasopressors

Phenylephrine
Epinenephrine
Norepineprine

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Is there a change in MAC with hyperthyroid patients

NO!!!

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Thiopental has what activity due to its structure

antithyroid

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Fluroide nephrotoxicity is a potential with hyperthyroid patients related to

Sevoflurane administration and increased metabolic rate which leads to increased metabolism of sevo

*Sevo metabolized 2-5% normally

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Nitrous Oxide should be used cautiously because

PTU/Methimazole causes bone marrow suppression and can be exaccerbated with N20

Should you reverse a hyperthyroid patient with anticholinergic

YES!!! but give slowly to avoid tachycardia

What condition is considered a hyperthyroid emergency

Thyroid storm

What is the Differential Diagnosis with thyroid storm

MH NMS Pheochromocytoma Light anesthesia *Always err on the most catastrophic diagnosis

What are the manifestations of thyroid storm

``` Hyperthermia Tachycardia Dysrhytmias Myocardial ischemia CHF agitation/confusion ```

Onset of thyroid storm appears

6-24 hours post surgery

Treatment of thyroid storm includes

``` 100% oxygen IV fluids (cold or room temp) Iodine Propylthiouracil Hydrocortisone Propranolol Meperidine for shivering cooling blankets/tylenol for fever Digoxin for HF with a.fib with RVR CORRECT CAUSE ART line/ABG, Electrolytes ```

What is a subtotal thyroidectomy indicated for

failed medical management CA Symptomatic goiter- can infringe on resp. system

A goiter predicts possible airway difficulty in 5-8% of patients because of the goiters

Location *Consider awake FOI

Name three main complicatons associated with subtotal thyroidectomy

Recurrent laryngeal nerve palsy - unilateral injury-hoarseness (voice quality) - bilateral injury-Stridor (requires reintubation) Hematoma formation -IMMEDIATE decompression (resp. risk) Hypoparathyroidism - acute hypocalcemia within 12-72 hours - presents with LARGYNGEAL STRIDOR

HYPOthyroidism manifestations include

``` Weight gain Cold intolerance muscle fatigue lethargy constipation hypoactive reflexes BRADCARDIA DECREASED MYOCARDIAL contractility DECREASED STROKE VOLUME/CO Peripheral vasoconstriction ```

What is the Emergency associated with Hypothyroidism

Myxedema Coma

S/S of Myxedma coma include

``` Altered mental status HYPOVENTILATION HYPOTHERMIA HYPONATREMIA HYPOGLYCEMIA CHF Lactic acidosis ```

Minimal preop sedation with hypothroid patients is indicated because

patients are VERY sensitive and can lead to drug-induced respiratory depression *patients will fail to respond to hypoxia with increased Vm

Hypothyroid patients that are hypotensive should be treated with what agonist

EPHEDRINE * Only slightly increases SVR relative to phenylephrine and agonizes beta receptors of heart (increase contractility, HR, etc) * Phenylephrine offers no beta effects so already decreased contractility of hypothyroid patients could lead to CV compromise

HyperParathyroidism is caused by

adenomas, renal disease

Treatment of choice for hyperParathyroidism include

surgery

Clinical symptoms of hyperPthyroidism are related to

hypercalcemia

Pituitary adenomas may result in over or under release of hormones

both

Pituitary adenomas most commonly secrete

GH and /or | Prolactin

A growth hormone secreting tumor leads to what phenotype

acromegally

Acromegally patients are at an increased risk for what perioperatively

difficult airway | postop respiratory complications

Patients with panhypopituitarism will need what

hormone replacement therapy *esp. cortisol, levothyroxine, and DDAVP

Conn disease is associated with what adrenal cortex disorder

hyperaldosteronism

What are the manifestations of hyperaldosteronism

HTN Hypervolemia Hypokalemia Alkalosis

Anesthetic goals for a patient with hyperaldosteronism include

correction of fluid and electrolyte preoperatively | **Give spironolactone and potassium

Cushing disease is caused by excessive pituitary secretion of

ACTH

Cushing syndrome results in

excessive level of cortisol production of from the zona fascicularis of the adrenal gland

Manifestations of Cushing syndrome include

``` HTN Hyperglycemia Weight gain Muscle wasting via proteolysis and weakness Osteoporosis ```

Anesthetic considerations for a patient with Cushing syndrome include

Correction of fluid/ electrolyte preoperatively Careful positioning Increased sensitivity to NMB *Although Etomidate transiently decreases synthesis and release of cortisol, IT HAS NO EFFEC

What are three concerns related to adrenalectomy

Intraoperative glucocorticoid replacement -hydrocortisone 100 mg IVq8h Blood loss -adrenal gland extremely vascular Pneumothorax-penetration of pleura

Addison's disease is associated with

adrenal insufficiency

Clinical manifestations of Addison's is r/t

aldosterone and cortisol deficiencies

What emergency is associated with Addison's disease

Addisonian crisis

What effect can stress have on an Addisons patient who is steroid-dependent

Addisonian crisis

S/S of Addisonian crisis include

CV collapse Fever Hypoglycemia CNS depression

In the adrenal insufficient patient, patient's cannot respond to surgical stress if they've recieved

Suppressive doses of steroids

What constitutes suprressive doses of steroids

5 mg qd > 2 weeks, within last year

List two methods of perioperatively replacement of hydrocortisone

Hydrocortisone 25 mg IV at time of induction followed by hydrocortisone infusion, 100 mg over 24 hours OR Hydrocortisone 100 mg before, during, and after surgery

Unexplained intraoperative hypotension suggests

adrenal failure

What induction agent must be avoided

etomidate

Pheochromocytoma is a tumor in which cells

Chromaffin cells in the medulla of the adrenal glands

What is the curative rate in removing tumors assocated with pheochromocytoma

> 90%

Death associated with Pheochromoocytoma are associated with

CV system *morbidity is r/t to tumor size and degress of catecholamine secretion

Most tumors associated with Pheo.. are localized to which gland

right side

95% of pheo's are located

along the paravertebral sympathetic chain in the abdomen

HTN assoc. with pheo can place patient's at risk for

Cerebrovascular hemorrhage HF Dysrhythmias MI

Pheo can masquerade as

How is the Diagnosis of Pheo made

Measuring VMA and uncongjutated NOR/EPI

How should Pheo patient's HTN be treated

Alpha-blockers first and IV administration Then, Beta blockage for continued tachycardia -Esmolol Patient's recieving < 48 hours of medical management need an infusion of nitroprusside or nicardipine during induction/surgical stimulation

Why should histamine liberating drugs be avoided in the pheo patient

histamine causes vasodilation which can synergistically react with alpha, beta blockers

After the pheo tumor has been removed, the anesthetist should prepare for

hypotension bradycardia