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620 Advanced Pharmacology > Steroids and Anesthetic Considerations > Flashcards

Steroids and Anesthetic Considerations Flashcards

1
Q

How does the hypothalamus know you need more cortisol?

A

CRH is stimulated in the anterior pituitary from decreased cortisol -> ACTH

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2
Q

When are cortisol levels the highest? Lowest?

A

Cortisol levels are highest in the morning (20ug/dL) and lowest at night (5ug/dL)

(this is why pts have MI’s in the AM)

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3
Q

What are 3 physiological factors that stimulate the HPA axis

A
  1. Hypoglycemia
  2. Trauma/sepsis
  3. Alpha & Beta agonists
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4
Q

Four factors that inhibit the HPA axis

A
  1. Adrenocorticotropic hormone (ACTH)
  2. Increased cortisol
  3. General anesthesia
  4. Etomidate
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5
Q

What is secreted from the Zona Glomerulosa?

A

Primarily mineral corticoid = Aldosterone

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6
Q

What is secreted from the Zona Fasiculata?**

A

Primarily glucocorticoid = Cortisol

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7
Q

What is secreted from the Zona Reticularis

A

Sex hormones

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8
Q

Stimulation of the HPA axis results in Cortisol, what are 4 systemic results of cortisol release in the body.

A
  1. Gluconeogenesis
  2. Protein mobilization
  3. Fat mobilization
  4. Stabilizes lysosomes
  • Increase HR and BP allows for the flight or fight response
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9
Q

What happens when you take synthetic cortisol for long periods of time?

A

The body thinks it’s naturally produced cortisol and it creates a negative feedback and shuts off

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10
Q

How should you stop taking a steroid ?

A

Need to be weaned off slowly to wake up the system

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11
Q

Who should receive steroids preoperatively?

A
  • Pts taking Prednisone 5 mg/d or equivalent for > 2 weeks within 1 yr. (Old method)
  • Pts taking Prednisone 20 mg/d or equivalent for > 3 weeks within 1 yr. (New method).
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12
Q

The HPA axis dysfunction is dependent on the _______ and _______ of steroid therapy.

A
  1. Dose

2. Duration

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13
Q

How long does it take for Cortisol levels to return to normal after stopping glucocorticoid treatment?

A

10 - 11 months
- the brain is still able to work & send signals so much that the ACTH levels rise, increasing the risk of adrenal insufficiency

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14
Q

What determines the potency of mineralocorticoid and glucocorticoid therapy?

A

the chemical structure

introduction of fluorine enhances activity

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15
Q

What steroid is most like the body’s natural cortisol?

A

Hydrocortisone

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16
Q

Cortisol (Hydrocortisone) potency? Na retention? 1/2 life?

A

Potency = 1
Na Retention = 1
1/2 life = 8-12 hours

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17
Q

Prednisone potency? Na retention? 1/2 life?

A

Potency = 4
Na Retention = 0.8
1/2 life = 18-36 hours

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18
Q

Dexamethasone (Decadron) potency? Na retention? 1/2 life?

A

Potency = 25
Na Retention = 0
1/2 life = 36-54 hours

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19
Q

What is the drug of choice for Acute Adrenal Crisis?

A

Hydrocortisone

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20
Q

What are the various steroids and their Equipotent dosages?

What is the most potent?**

A 
Hydrocortisone = 100 mg
Prednisone = 25 mg
Methylprednisolone = 20 mg
Dexamethasone = 3.75 (4 mg) = 25x's the potency**
21
Q

How are exogenous steroids absorbed?

A
  • inhalation & mucosal and skin applications
22
Q

If a patient with asthma or eczema uses a steroid everyday, do they need a steroid prep?*

Do they have HPA axis suppression?

A

No

23
Q

What is the body’s physiologic short term stress response?

A

Hypothalamus -> signals preganglionic sympathetic fibers -> adrenal medulla = catecholamines =

  • Increased heart rate
  • Increased BP
  • Liver converts glycogen to glucose
  • Dilation of bronchioles
  • Changes in bf patterns leading to increased alertness, decreased digestive system activity, & reduced UO
  • Increased metabolic rate
24
Q

What is the effect of a more prolonged stress response?

A

Hypothalmus (CRH) -> anterior pituitary (ACTH) -> adrenal cortex = mineralocorticoids & Glucocorticoids

Mineralocorticoids = Aldosterone

Glucocorticoids = Cortisol

25
Q

Long term stress response and the effects of Mineralocorticoids?

A
  1. Retention of sodium & water by kidneys

2. Increased blood volume & blood pressure

26
Q

Long term stress response and the effects of Glucocorticoids?

A
  1. Proteins & fats converted to glucose or broken down for energy
  2. Increased blood sugar
  3. Suppression of immune system
27
Q

What is the normal daily output of cortisol?

A

20 mg

28
Q

What is the Old maximum daily output of cortisol?

A

300 mg

  • This is why we give 300 mg in the OR
29
Q

What is the New maximum daily output of cortisol?

A

200 mg

30
Q

Cortisol receptors on the heart cause?

A

Increase BP & HR

31
Q

What increases cortisol levels the most?

A

Septic Shock

32
Q

**What are the signs and symptoms associated with Acute Adrenal Crises?

A
  • Neurologic - brain shuts off (don’t see in OR)
  • Hemodynamic - massive vasodilation & decrease BP*
  • **Metabolic =
    • Hypoglycemic
    • Hypovolemia
    • Hyponatremia*
    • Hyperkalemic*
    • Metabolic acidosis
33
Q

When treating AAC how should you replace the steroid?

A

Give steroid prep in a slow piggyback

- if given too fast the patient will bounce off the wall d/t sympathetic stimulation

34
Q

What is the first sign of AAI?*

A

Hypotension not responsive to pressors = REFRACTORY HYPOTN**

  • this is d/t not seeing the neuro response d/t ETT w/ sedation
35
Q

Treatment of Acute Adrenal Crisis?

A 
Hydrocortisone 100 mg IV - initially
Hydrocortisone 200 mg IVPB over 24 hrs
   - Combined 300 mg
Fluid replacement
Glucose replacement & monitoring
Hemodynamic monitoring
Vasopressor & inotropic support as needed (Vaso & methylene blue)
36
Q

What are the steroid replacements for minor surgical stress?

A

25 mg hydrocortisone or equivalent

inguinal hernia

37
Q

What are the steroid replacements for Moderate surgical stress?

A

50 - 75 mg/dL of hydrocortisone or equivalent for 1-2 days, then resume preoperative dosage
(cholecystectomy, hysterectomy, colon resection)

38
Q

What are the steroid replacements for Major surgical stress?

A

100 - 150 mg/dL of hydrocortisone or equivalent for 2-3 days then resume preoperative dosage
(AAA repair, cardiac bypass)

39
Q

How does Etomidate inhibit Cortisol?**

A

Etomidate blocks 11 Beta-hydroxylase - the enzyme responsible for converting 11-deoxycortisol to cortisol

40
Q

Does propofol inhibit cortisol?

A

No. Propofol does not inhibit the cortex therefore cortisol levels go up w/ surgery

41
Q

When is decadron most efficacious?

A

If given prior to induction of anesthesia b/c its slow

- we don’t do this b/c of perineal burning

42
Q

What is the most effective dose of Decadron? Onset? Peak? DoA?

A

4mg

  • onset 1 hr
  • peak 8 - 10 hr
  • DoA 72 hr
43
Q

Should you give 100 mg hydrocortisone for potential adrenal insufficiency and decadron for PONV preoperatively?

A

Do not give both if they are at risk.

Risk is not an indication for AAI hydrocortisone, only if in crisis.

44
Q

How does septic shock decrease cortisol? and the treatment?

A

Sepsis increases nitric oxide = vasodilator
- Cytokines decrease #’s/affinity of glucocorticoid receptors for cortisol

  • 200 mg hydrocortisone if decreased BP after vol. resuscitation & max vasopressors
45
Q

Where do steroids work in the intrinsic pathway?

A

Steroids decrease the conversion of phospholipase A2 to Arachidonic Acid & decrease the conversion of AA to Cyclooxygenase & Lipoxygenase = decrease inflammation & pain

46
Q

Given perineural Dexamethasone 4 mg compared w/ IV is associated with what outcomes?

A
  • Decreased pain scores
  • Reduced opioid consumption
  • Less PONV
47
Q

How long does the adrenal cortical suppression last?**

A

24- 48 hours

48
Q

Is cortisol the same chemical structure as aldosterone?*

A

Yes

49
Q

Where is cortisol transported to in the brain?*

A

Anterior pituitary

620 Advanced Pharmacology (9 decks)

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