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N935 Advanced Pathophysiology > adrenal disease > Flashcards

adrenal disease Flashcards

1
Q

diseases of the adrenal cortex

A

hyperadrenocorticism/cushings
hyperaldosteronism/conn’s
hypoadrenocorticism/addison’s
hypoaldosteronism

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2
Q

diseases of the adrenal medulla

A

pheochromocytoma

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3
Q

3 zones of the adrenal cortex

A

zona glomerulosa, zona fasciculata, zona reticularis

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4
Q

zona glomerulosa deals with which hormone

A

aldosterone (mineralcorticoid)

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5
Q

zona fasciculata deals with which hormone

A

cortisol (glucocorticoids)

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6
Q

zona reticularis deals with which hormone

A

androgens

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7
Q

what is the outer portion of the adrenal gland and what is the inner portion?

A 
outer = cortex
inner = medulla
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8
Q

the adrenal gland has one of the highest rates of

A

blood flow per gram of tissue

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9
Q

what makes up the HPA axis?

A

hypothalamus, anterior pituitary, and adrenal cortex

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10
Q

the adrenal medulla secretes

A

epi (80%) and norepi (20%)

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11
Q

cortisol physiological functions

A

blood glucose regulation, protein turnover, fat metabolism, sodium, potassium, and calcium balance, maintenance of CV tone, modulation of tissue response to injury/infection, survival from stress

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12
Q

what is the most important function of cortisol?

A

survival as a result from stress

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13
Q

Cushings syndrome vs cushings disease

A

syndrome - excess cortisol secretion or endogenous steroids

disease - inappropriate ACTH from pituitary

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14
Q

Cushing’s/hyperadrenocorticism can be ___

A

ACTH dependent or independent

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15
Q

ACTH dependent hyperadrenocorticism/Cushings caused from

A

pituitary corticotroph tumors, non-endocrine tumors in the lung, kidney, or pancreas (ectopic corticotropin syndrome)

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16
Q

ACTH independent hyperadrenocorticism/Cushings caused from

A

benign or malignant adrenocortical tumors

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17
Q

Cushings signs and symptoms

A

sudden weight gain, thickening of facial fat (moon face), electrolyte abnormalities, systemic HTN, glucose intolerance, menstrual irregularities, decreased libido, skeletal muscle wasting, depression and insomnia, and osteoporosis, hypercoaguable (risk of thrombosis)

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18
Q

diagnosis of cushings

A 
24 urine collection, plasma cortisol levels = if both elevated = cushings
CRH stimulation test
dexamethasone suppression test
inferior petrosal sinus sampling
CT and MRI once diagnosis is confirmed
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19
Q

Dexamethasone suppression test

A

given high dose of dexamethasone if a pituitary tumor -maintains negative feedback system and can suppress ACTH

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20
Q

cushings treatment

A

based on cause
surgical - transphenoidal microadenectomy (if pituitary tumor), adrenalectomy (partial or total)
irradiation

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21
Q

electrolytes we would want to check preoperatively in a cushings patient

A

check for hypokalemia and hypernatremia

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22
Q

what acid base balance would you expect to see with cushings?

A

hypokalemic metabolic alkalosis

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23
Q

positioning considerations for cushings

A

may have osteoporosis/osteomalacia (risk for vertebral compression fractures), can be obese, careful with airway management, use appropriate padding

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24
Q

anesthetic considerations for muscle weakness in cushings

A

hypokalemia is usually the culprit, decreased requirements for muscle relaxants, use a PNS, maintain 1 twitch if possible (know that they are reversible), consider intubating (may have weak respiratory muscles)

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25
Q

considerations for a unilateral or bilateral adrenalectomy

A

100 mg glucocorticoid/24 hours, reduce dose over 3-6 days postop, may need to give mineralcorticoid supplementation

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26
Q

some inhalational agents depress adrenal response to

A

stress and ACTH

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27
Q

etomidate can lead to

A

adrenocortical suppression with long term infusion

it inhibits enzymes involved in cortisol and aldosterone synthesis

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28
Q

complications with transphenoidal microadenomectomy

A

VAE, transient diabetes insipidus (DI), meningitis

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29
Q

complications with laparoscopic adrenalectomy

A

risk for nerve injury in upper extremity d/t positioning

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30
Q

complications with open adrenalectomy

A

pulmonary complications from retraction which can lead to atelectasis

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31
Q

right adrenalectomy complication

A

could knick the liver or small intestine

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32
Q

left adrenalectomy complication

A

could knick the spleen, pancreas, or blood vessels to the kidneys

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33
Q

primary hyperaldosteronism (conn’s) definition

A

an excess secretion of aldosterone from a functional tumor

34
Q

conn’s syndrome is more common in

A

women > men and rarely in children

35
Q

secondary hyperaldosteronism

A

increased circulating serum renin stimulates the release of aldosterone (renovascular hypertension)

36
Q

Conn’s disease signs and symptoms

A 
non-specific and some can be asymptomatic
systemic HTN (HA, diastolic 100-125mmHg), hypokalemia (skeletal muscle cramps and weakness, metabolic alkalosis)
37
Q

systemic HTN in Conn’s disease is reflective of

A

aldosterone induced sodium and fluid retention and can be resistant to treatment!

38
Q

anesthesia management for hyperaldosteronism

A

correct hypokalemia and HTN with spironolactone
assess cardiac/renal status
avoid hyperventilation!
adequate fluids with vasodilators/diuresis
exogenous cortisol 100mg/day

39
Q

Addison’s Disease

A

primary adrenal insufficiency from an idiopathic/autoimmune cause or from bacterial/fungal/HIV infection

40
Q

Someone with Addison’s disease typically don’t show symptoms until

A

90% of the adrenal cortex has been destroyed

41
Q

Addison’s disease is a deficiency of

A

all adrenal cortex secretions = mineralocorticoids, glucocorticoids, and androgens

42
Q

Someone with Addison’s disease is very susceptible to

A

death because their body cannot handle stress

43
Q

Addison’s signs and symptoms

A

fatigue, muscle weakness, hypotension, weight loss, anorexia, NVD, increased BUN and hemoconcentration (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia), abdominal/back pain, hyperpigmentation

44
Q

diagnosis of Addison’s

A

cortisol level <20 ug/dL after ACTH stimulation test 30 and 60 minutes after administration of ACTH

45
Q

normal response to ACTH stimulation test

A

plasma cortisol levels >25 ug/dL

46
Q

Addisonian crisis is triggered in

A

steroid dependent patients who do not receive increased dose during stress that leads to circulatory collapse!

47
Q

signs and symptoms of addisonian crisis

A

hypoglycemia, electrolyte imbalance, depressed mentation

48
Q

treatment of addisonian crisis

A

IV cortisol 100 mg q4-6 h for 24 h, D5/0.9% NS, colloid and whole blood, inotropic support if needed

49
Q

anesthetic management of addison’s

A

exogenous corticosteroids
25 mg for minor surgery
100mg bolus with infusion at 10mg/hr for major surgery
avoid etomidate?
patients are sensitive to inhalational agents myocardial depressive effects
titrate muscle relaxants and use PNS

50
Q

intraoperative hypotension treatment in addison’s

A

rule out other causes, measure CVP - do they need fluid?

try vasopressor, cortisol 100mg, fluids, and may need invasive monitoring

51
Q

hypoaldosteronism

A

congenital deficiency

or from hyporeninemia or nonsteroidal inhibitors of prostaglandin synthesis

52
Q

hyporeninemia can cause hypoaldosteronism due to

A

long standing diabetes and renal failure and/or treatment with ACEi leading to a loss of angiotensin stimulation

53
Q

nonsteroidal inhibitors of prostaglandin synthesis may inhibit

A

renin release and exacerbate condition in presence of renal insufficiency

54
Q

signs and symptoms of hypoaldosteronism

A

hyperkalemic acidosis, hyponatremia, myocardial conduction defects

55
Q

hypoaldosteronism treatment

A

mineralocorticoids - fludrocortisone

liberal sodium intake

56
Q

pheochromocytoma is a

A

catecholamine secreting tumor

57
Q

pheochromocytomas originate in

A

the adrenal medulla and related tissues elsewhere in the body (95% in abdominal cavity, 10% involve both adrenals)

58
Q

pheochromocytomas are more common in

A

young to mid adult life adults (30s-50s)

59
Q

predominant symptoms of pheochromocytoma

A

HTN continuous or paroxysmal, HA, diaphoresis/pallow, palpitations/tachycardia

60
Q

associated symptoms with pheochromocytoma

A

orthostatic HoTN, anxiety, tremor, chest pain, epigastric pain, flushing, painless hematuria

61
Q

is epi or NE secreted more in pheochromocytoma?

A

NE is released more than epi

62
Q

diagnosis of pheochromocytoma

A

urine test - not for definitive diagnosis
plasma free metanephrines (normetanephrine >400, metanephrine >220)
CT/MRI

63
Q

treatment of pheochromocytoma

A

surgical excision only definitive treatment
phenoxybenzamine or prazosin to produce alpha block
restore intravascular volume
restore release of insulin with alpha block
beta block

64
Q

Why do we always alpha block before beta block?

A

if a nonselective beta block is administered in absence of alpha block heart depressed by beta block unable to maintain CO with unopposed alpha mediated vasoconstriction

65
Q

pheochromocytoma patients may have hyperglycemia because

A

there is less circulating insulin with increased glycogenolysis

66
Q

preop criteria for pheochromocytoma

A

no BP reading >165/90 for 48 hours prior to surgery
BP upon standing should not be <80/45
ECG without ST-T wave changes that aren’t already permanent
No more than 1 PVC every 5 minutes to avoid cardiac arrest

67
Q

pheochromocytoma patients may have a falsely elevated

A

Hct so get a type and cross and prehydrate

68
Q

what is an important goal for pheochromocytoma patients

A

fluid replacement/status

69
Q

anesthetic considerations for pheochromocytoma

A

aline, heavy premedication, gentle positioning, epidural or combined anesthetic

70
Q

induction considerations with pheochromocytoma

A

prepare for hyperdynamic BP
give lidocaine 1-2mg/kg
give sufentanil 0.5-1 mcg/kg or fentanyl 3-5 mcg/kg
give propofol 3mg/kg

71
Q

what drugs would you avoid in pheochromocytoma

A 
morphine and atracurium d/t histamine relase which stimulates catecholamine release 
pancuronium and atropine (increase HR)
metoclopramide
halothane
succinylcholine
72
Q

what is an alpha blocker of choice for pheochromocytoma

A

phentolamine

73
Q

what is a beta blocker of choice for pheochromocytoma

A

esmolol

74
Q

nitroprusside dose

A

1-2 mcg/kg

75
Q

why is nitroprusside preffered in pheochromocytoma treatment

A

fast on and fast off

76
Q

phentolamine considerations

A

tachyphylaxis, tachycardia, and longer duration

77
Q

with surgical ligation of the pheochromocytoma what should we be prepared for?

A

hypotension! so stop antihypertensives, good communication with surgeon, decrease inhalational agent, try volume first, use phenylephrine and NE for pressors

78
Q

why might you avoid succinylcholine in pheochromocytoma patients?

A

causes fasciculations of abdominal muscles which can cause release of catecholamines from the tumor

79
Q

postop considerations for pheochromocytoma patients

A

50% stay hypertensive d/t elevated catecholamine levels for 10 days
may be hypoglycemic
need steroid supplementation if had bilateral adrenalectomies or hypoadrenalism
need adequate pain control

80
Q

if postoperative HTN is lasting longer than 10 days what should you consider?

A

there is a presence of occult tumors or they are fluid overloaded

81
Q

50% of undiagnosed pheochromocytomas die

A

under general anesthesia

N935 Advanced Pathophysiology (15 decks)

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