Principles-Management of Endocrine Disorders Flashcards

1
Q

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

A

cardiovascular

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2
Q

Thyroid hormone causes what principle effect on the CV receptors

A

Increases its number thereby effecting the tissues reponses to sympathetic stimuli

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3
Q

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

A

t4 increased
t3 increased
tsh decreased

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4
Q

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

A

t4 increased
t3 increased
tsh increased

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5
Q

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

A

t4 decreased
t3 decreased
tsh increased

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6
Q

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

A

t3 decreased
t4 decreased
tsh decreased

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7
Q

What is the most common cause of hyperthyroidism

A

Graves disease (a multinodular diffuse goiter)

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8
Q

What are the clinical manifestations of hyperthyroidism

A
Weight loss
diarrhea
skeletal muscle weakness
warm/moist skin
heat intoloerance
exophthalmos
nervousness
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9
Q

What are the CV manifestations of hyperthyroidism

A

Increased left ventricular contractility
Increased ejection fraction
Tachycardia
Hypertension

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10
Q

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

A

Euthyroid

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11
Q

What four medications are used to treat hyperthyroidism

A

Beta-adrenergic antagonists
Iodine
Methimazole
Propylthiouracil

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12
Q

A SYMPTOMATIC hyperthyroid patient requiring emergency surgery should receive

A

beta blockers to achieve a HR < 90

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13
Q

Should hyperthroid patients continue therapy up to the morning of surgery

A

Yes

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14
Q

Are Euthyroid patients considered normal for anesthesia

A

yes

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15
Q

What is the main goal for treating symptomatic hyperthyroid patients

A

Prevent exagerrated sympathetic response

-avoid medications that increase SNS discharge

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16
Q

Name a NDMB that should be avoided in hyperthyroid patients

A

pancuronium

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17
Q

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

A

Ketamine

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18
Q

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

A

Rapid titration of desflurane

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19
Q

The incidence of what neuromuscular disease is increased with hyperthyroid patients

A

Myasthenia Gravis

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20
Q

Treating hypotension for symptomatic hyperthyroidism should be done with what

A

Direct-acting vasopressors

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21
Q

Name commonly used Direct-acting vasopressors

A

Phenylephrine
Epinenephrine
Norepineprine

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22
Q

Is there a change in MAC with hyperthyroid patients

A

NO!!!

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23
Q

Thiopental has what activity due to its structure

A

antithyroid

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24
Q

Fluroide nephrotoxicity is a potential with hyperthyroid patients related to

A

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

*Sevo metabolized 2-5% normally

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25
Q

Nitrous Oxide should be used cautiously because

A

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

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26
Q

Should you reverse a hyperthyroid patient with anticholinergic

A

YES!!! but give slowly to avoid tachycardia

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27
Q

What condition is considered a hyperthyroid emergency

A

Thyroid storm

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28
Q

What is the Differential Diagnosis with thyroid storm

A

MH
NMS
Pheochromocytoma
Light anesthesia

*Always err on the most catastrophic diagnosis

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29
Q

What are the manifestations of thyroid storm

A
Hyperthermia
Tachycardia
Dysrhytmias
Myocardial ischemia
CHF
agitation/confusion
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30
Q

Onset of thyroid storm appears

A

6-24 hours post surgery

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31
Q

Treatment of thyroid storm includes

A
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
32
Q

What is a subtotal thyroidectomy indicated for

A

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

33
Q

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

A

Location

*Consider awake FOI

34
Q

Name three main complicatons associated with subtotal thyroidectomy

A

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
35
Q

HYPOthyroidism manifestations include

A
Weight gain
Cold intolerance
muscle fatigue
lethargy 
constipation
hypoactive reflexes
BRADCARDIA
DECREASED MYOCARDIAL contractility
DECREASED STROKE VOLUME/CO
Peripheral vasoconstriction
36
Q

What is the Emergency associated with Hypothyroidism

A

Myxedema Coma

37
Q

S/S of Myxedma coma include

A
Altered mental status
HYPOVENTILATION
HYPOTHERMIA
HYPONATREMIA
HYPOGLYCEMIA
CHF
Lactic acidosis
38
Q

Minimal preop sedation with hypothroid patients is indicated because

A

patients are VERY sensitive and can lead to drug-induced respiratory depression

*patients will fail to respond to hypoxia with increased Vm

39
Q

Hypothyroid patients that are hypotensive should be treated with what agonist

A

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
40
Q

HyperParathyroidism is caused by

A

adenomas, renal disease

41
Q

Treatment of choice for hyperParathyroidism include

A

surgery

42
Q

Clinical symptoms of hyperPthyroidism are related to

A

hypercalcemia

43
Q

Pituitary adenomas may result in over or under release of hormones

A

both

44
Q

Pituitary adenomas most commonly secrete

A

GH and /or

Prolactin

45
Q

A growth hormone secreting tumor leads to what phenotype

A

acromegally

46
Q

Acromegally patients are at an increased risk for what perioperatively

A

difficult airway

postop respiratory complications

47
Q

Patients with panhypopituitarism will need what

A

hormone replacement therapy

*esp. cortisol, levothyroxine, and DDAVP

48
Q

Conn disease is associated with what adrenal cortex disorder

A

hyperaldosteronism

49
Q

What are the manifestations of hyperaldosteronism

A

HTN
Hypervolemia
Hypokalemia
Alkalosis

50
Q

Anesthetic goals for a patient with hyperaldosteronism include

A

correction of fluid and electrolyte preoperatively

**Give spironolactone and potassium

51
Q

Cushing disease is caused by excessive pituitary secretion of

A

ACTH

52
Q

Cushing syndrome results in

A

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

53
Q

Manifestations of Cushing syndrome include

A
HTN
Hyperglycemia
Weight gain
Muscle wasting via proteolysis and weakness
Osteoporosis
54
Q

Anesthetic considerations for a patient with Cushing syndrome include

A

Correction of fluid/ electrolyte preoperatively
Careful positioning
Increased sensitivity to NMB

*Although Etomidate transiently decreases synthesis and release of cortisol, IT HAS NO EFFEC

55
Q

What are three concerns related to adrenalectomy

A

Intraoperative glucocorticoid replacement
-hydrocortisone 100 mg IVq8h

Blood loss
-adrenal gland extremely vascular

Pneumothorax-penetration of pleura

56
Q

Addison’s disease is associated with

A

adrenal insufficiency

57
Q

Clinical manifestations of Addison’s is r/t

A

aldosterone and cortisol deficiencies

58
Q

What emergency is associated with Addison’s disease

A

Addisonian crisis

59
Q

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

A

Addisonian crisis

60
Q

S/S of Addisonian crisis include

A

CV collapse
Fever
Hypoglycemia
CNS depression

61
Q

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

A

Suppressive doses of steroids

62
Q

What constitutes suprressive doses of steroids

A

5 mg qd > 2 weeks, within last year

63
Q

List two methods of perioperatively replacement of hydrocortisone

A

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

64
Q

Unexplained intraoperative hypotension suggests

A

adrenal failure

65
Q

What induction agent must be avoided

A

etomidate

66
Q

Pheochromocytoma is a tumor in which cells

A

Chromaffin cells in the medulla of the adrenal glands

67
Q

What is the curative rate in removing tumors assocated with pheochromocytoma

A

> 90%

68
Q

Death associated with Pheochromoocytoma are associated with

A

CV system

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

69
Q

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

A

right side

70
Q

95% of pheo’s are located

A

along the paravertebral sympathetic chain in the abdomen

71
Q

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

A

Cerebrovascular hemorrhage
HF
Dysrhythmias
MI

72
Q

Pheo can masquerade as

A

MH

73
Q

How is the Diagnosis of Pheo made

A

Measuring VMA and uncongjutated NOR/EPI

74
Q

How should Pheo patient’s HTN be treated

A

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

75
Q

Why should histamine liberating drugs be avoided in the pheo patient

A

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

76
Q

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

A

hypotension

bradycardia