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N935 Pathophysiology > Adrenal Glands > Flashcards

Adrenal Glands Flashcards

1
Q

What has multiply functions & secretes a variety of hormones?

A

adrenal glands

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2
Q

What are the size of the adrenal glands?

A

no larger than a walnut and weighs less then a grape

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3
Q

What are the two portions of each adrenal glands?

A

cortex

medulla

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4
Q

What does the adrenal cortex?

A

80-90% glands
zona glomerulosa: glucocorticoids (cortisol)
zona fasciculata: mineralocorticoids (aldosterone)
zona reticularis: Androgen (sex hormones)
outer aspect

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5
Q

What is the adrenal medulla

A

10-20% inner portion
epinephrine 80%
Norepinephrine 20%

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6
Q

How much blood flow do the adrenal glands receive?

A

one of the highest rates of blood flow per gram of tissue

separate blood flow from the kidneys

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7
Q

Describe the regulation of adrenal glands?

A

complex regulation
hypothalamus, anterior pituitary
adrenal cortex
Hypothalamus-> CRH-> pituitary gland-> ACTH->adrenal gland-> cortisol

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8
Q

What are the eight physiological functions of the adrenal glands?

A

blood glucose regulation
protein turnover
fat metabolsim
sodium, postassium and calcium
maintenance of cardiovascular tone
modulation of tissue response to injury or infection
survival as result of stress (most important)

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9
Q

What is excessive cortisol secretion called?

A

cushing syndrome

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10
Q

What are the two types of cushing syndrome?

A

independent and dependent

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11
Q

What is independent ACTH?

A

benign or malignant adrenocortical tumors

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12
Q

What is dependent ACTH?

A

hyperplasia
cushing disease pituitary corticotroph tumors (microademonas)
non endocrine tumors of lung, kidney, or pancreas
ectopic corticotropin syndrome

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13
Q

What are twelve signs and symptoms of cushing syndrome?

A 
moon face
sudden weight gain
electrolyte abnormalities
systemic hypertension
glucose intolerance (hyperglycemic)
menstrual irregularies
decreased libido
skeletal muscle wasting
depression and insomnia
osteoporosis
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14
Q

How do you diagnosis cushing syndrome?

A 
plasma and urine cortisol levels
urinary 17 hydroxycorticosteroids 24 hour urine collection
plasma cortisol levels
if both elevated-> cushing's syndrome
CRH stimulation test
dexamethasone suppression test
inferior petrosal sinus sampling (IPSS)
ct and mri once diagnosis is confirmed
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15
Q

Surgical treatments for Cushing syndrome

A

transphenoidal microadenectomy
adrenalectomy
irradiation

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16
Q

What are anesthetic considerations for cushings?

A 
pre-operative evaulation 
positioning
skeletal muscle weakness
cortisol
blood loss
choice of agents
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17
Q

What are preoperative considerations for Cushings?

A

HTN
intravascular volume
hypokalemia, hypernatremia
acid-base status : hypokalemic metabolic alkalosis
cardiac compromise CHF d/t BV and HTN
diabetes (check glucose level)
control with small amounts of IV sulin (1-5 units q hour)

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18
Q

Why is positioning important for cushing syndrome patients?

A

osteoporosis and osteomalacia (vertebral compression fractures)
obesity
use of appropriate padding
check position throughout case
care when moving to stretcher and use of roller

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19
Q

What are anesthetic considerations specific to muscle weakness for cushing syndrome patients?

A

hypokalemia contributing factor
decreased requirements for muscle relaxants
use a PNS
maintain 1 twitch if possible

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20
Q

How do you treat preoperatively hypokalemia in cushing syndrome?

A

treat pre-operatively 80-100mEq/day oral

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21
Q

Cortisol managment in Cushing’s syndrome

A

unilateral or bilateral adrenalectomy
100mg glucocorticoid/ 24hours usually started intraoperatively
dose reduced over 3-6 days to maintain dose
mineralcorticoid may also need supplementation
unilateral continued therapy may not be required depending upon remaining gland

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22
Q

Describe blood loss in cushing syndrome?

A 
may be significant
type and screen
major surgery (type and cross)
CVP
Aline
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23
Q

Describe the use of anesthetic agents in cushings

A

drugs or techniques are not likely to influence attempts to decrease cortisol levels
some inhalation agents depress adrenal response to stress and acth
changes caused by anesthetic agent or type are insignificant when compared to increase in cortisol secretion with surgical stress

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24
Q

What occurs with etomidate?

A

inhibits enzymes involved in cortisol and aldosterone synthesis
long term infusion: adrenocortical suppression

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25
Q

What are complications with transphenodial microadenomectomy?

A

VAE
transient diabetes insipidus
meninigitis

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26
Q

What are complications with an adrenalectomy (laparoscopic)

A

position

insufflation

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27
Q

What are complications with an adrenalectomy (open)

A

pulmonary complication
nerve injury
retraction to keep tissue and organs out of way
damage to spleen pancrease and BF to kidney

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28
Q

What is primary hyperaldosteroneism?

A

Conn’s syndrome

excess secretion of aldosterone from a functional tumor

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29
Q

Who does hyperaldosterone occur in?

A

women then men

30
Q

What is secondary hyperaldosteronism?

A

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

31
Q

What are signs and symptoms of COnn’s disease?

A

non specific and asymptomatic
Systemic HTN (headache/ diastolic BP 100-125) reflects aldosterone induced sodium retention and resulting increased fluid retention
may be resistant to treatment
Hypokalemia- skeletal muscle cramps, weakness and metabolic alkalosis
Not edematous

32
Q

Describe anesthesia management with hyperaldosteronism?

A

correct decreased K and HTN (spironolactone)
assess cardiac/ renal disease
avoid hyperventilation -> further decreases K
A line
adequate fluids with vasodilators/diuresis
check acid-base, electrolytes frequently
exogenous cortisol 100mg/24 hr

33
Q

What is addison’s disease?

A

primary adrenal insufficiency
idiopathic/autoimmune most common primary cause
no symptoms until 90% of adrenal cortex has been destoryed
deficiency of all adrenal cortex secretions (mineralcorticoids, glucocorticoids, androgens)

34
Q

What are signs and symptoms of addison’s? (11)

A 
chronic fatigue
muscle weakness
hypotension
weight loss
anorexia, N/V diarrhea
increased BUN/ hemoconcentrration due to hypovolemia
hyponatremia
hyperkalemia
hypoglycemia
abdominal or back pain
hyperpigmentation in sun-exposed areas and distal extremities
35
Q

How is addison’s disease diagnosed?

A

baseline plasma cortisol level < 20mcg/dL
cortisol levels are measured after 30-60 minutes following ACTH administration
normal response to plasma cortisol level >25 mcg/dL
positive test results yields poor response to ACTH and is indicative of adrenal cortex impairement

36
Q

What is an addisonian crisis?

A

triggered in steroid dependent who do not recieve increased dose during stress
stress-> circulatory collapse (hypoglycemia, electrolyte imbalance, depressed menatation)

37
Q

What is the treatment for addisonian crisis?

A

IV cortisol 100mg 4-6h for 24 hours
D5 0.9NS volume colloid whole blood
intropic support

38
Q

What are anesthetic management considerations for addison’s?

A

administer exogenous corticosteroids
take daily dose corticosteroids if prescribed
measure glucose levels preop and every hour (replace with dextrose solution)
check electrolytes frequently (K levels are concern) avoid LR
avoid etomidate
inhalation agents (sensitive to drug induced myocardial depression)
PNS- titrate muscle relaxants due to skeletal muscles weakness

39
Q

What are the recommended dose for minor surgery with addison’s

A

25mg hydrocortisone

40
Q

What is the recommended dose for major surgery with addison’s

A

100mg bolus followed with infusion 10mg/hr or 100mg every 6hours

41
Q

What are hypotension considerations for addison’s?

A

intraoperatively: rule out usual causes of shock and measure CVP

42
Q

How do you treat hypotension in Addison’s?

A

vasopressor (even if did not have effect before cortisol)
administer cortisol 100mg IV
fluids
invasive monitoring

43
Q

How does hypoaldosteronism occur?

A

congential deficiency
hyporeninemia (due to long standing diabetes and renal failure and/or treatment with ACEi-> loss of angiotensin stimulation)
NSAIDs inhibiting prostaglandin synthesis (inhibit renin release and exacerbate condition in presence of renal insufficiency)

44
Q

Signs and symptoms of hypoaldosteronism

A

hyperkalemic acidosis
severe hyperkalemia
hyponamtremia
myocardial conduction defects

45
Q

What is the treatment for hypoaldosteronism?

A

mineralcorticoids (fludrocortisone)

liberal sodium intake

46
Q

What is pheochromocytoma

A

catecholamine secreting tumor

47
Q

where is a pheochromocytoma found?

A

originated in the adrenal medulla and related tissues elsewhere in the body
> 95% found in abdominal cavity
10% found in both adrenal galnds
functional tumors in multiple sites are present in 20% of patients especially children

48
Q

When do pheochromocytomas mostly occur?

A

young to mid adult life

49
Q

What are the predominant symptoms of pheochromocytoma?

A

HTN continous or paroxysmal
headache
diaphoresis/pallor
palpitation/ tachycardia

50
Q

What are associated symptoms of pheochromocytoma?

A 
orthostatic hypotension
anxiety
tremor 
chest pain
epigatric pain
flushing (rare)
painless hematuria (rare)
51
Q

When is the timing of episodes for pheochromocytoma?

duration and frequency?

A

duration: one hour or less
frequency: daily to once every few months

52
Q

How do you diagnosis a pheochromocytoma?

A

urine tests
plasma levels
radiographic test to locate tumor (CT MRI)

53
Q

How do urine tests show pheochromocytoma?

A

useful for screening but unrelaible for definitive diagnosis

54
Q

how do plasma levels show pheochromocytoma?

A

reliably reflects the presence of pheo
measure plasma free metanephrine
normetanephrine > 400pg/ml
metanephrine 220pg/ml

55
Q

How do you treat a pheochromocytoma?

A

surgical excision
phenoxybenzamine (alpha 1 and 2) or prazosin (selective alpha 1) to produce alpha blockade
restore intravascular volume (decrease Hct evident)
restore release of insulin w/ alpha block
persistant tachy-beta block (esmolol)

56
Q

What do you not do with pheochromocytoma?

A

administer beta blocker in absence of alpha block heart depressed by beta block unable to maintain CO with unopposed alpha mediated vasoconstriction

57
Q

What will happen if you beta block then alpha block?

A

youll decrease the HR with BB and not decrease HR therefore the heart will be pumping against strong afterload causing heart failure

58
Q

What are pre-operative considerations for pheochromocytoma?

A

optimize the preoperative condition
history and labs
increased PVR (MI, ventricular hypertrophy, CHF, cardiomyopathy)
Hx of cerebral hemorrhage
hyperglycemia (decreased circulating insulin with increased glyconeolysis)

59
Q

What are pre-op criteria pheochromocytoma?

A

No BP reading > 165/90 for 48 hours prior to surgery
BP on standing should not be < 80/45
ECG without ST-T wave changes that are not permenant
no more then 1 PVC 1 5minutes

60
Q

What are anesethetic considerations for pheochromocytoma?

A 
good communication with surgeon
continue adrenergic blockade
fluid management 
hypovolemic- prehydrate
falsely elevated HCT-> type and cross
renal function
fluid replacement plan
heavy premedication
gentle positioning
combined GA/ lumbar epidural
epidural prior to induction
invasive monitoring
61
Q

What monitors are required for pheochromocytoma

A 
EKG
Aline (Bp control, electrolytes, glucose levels
TEE
CVP
UOP
temperature
PNS
62
Q

What should you prepare for with induction of pheochromocytoma?

A

hyperdynamic BP

63
Q

What is the drug cocktail for pheochromocytoma?

A 
lidocaine 1-2 mg/kg
opioid (no morphine-histamine release)
sufentanil (0.5-1 mcg/kg)
fentanyl (3-5mcg/kg)
propofol (3mg/kg)
64
Q

What are considerations for pheochromocytoma during laryngoscopy?

A

must have adequate depth inhalation agent to deepen
lidocaine 1-2 mg/kg IV 1 minute before
opioid: 100-200mcg sufentanil 10-20mcg to attenuate sympathetic response
nitroprusside 1-2 mcg/kg
phentoamine: alpha blocker
beta blocker: esmolol
no drugs that release histamine

65
Q

Intraoperative considerations for pheochromocytoma

A 
inhalation for maintenance 
1.5-2MAC more control than opioid technique
combine technique with epidural
opioid
muscle relaxant (vec/roc)
66
Q

What are blood pressure considerations for pheochromocytoma?

A

nitroprusside preferred
phentolamine (tachyphylaxis, tachycardia, longer duration)
magnesium sulfate
CCB

67
Q

How do you maintain HR with pheochromocytoma?

A

esmolol (preferred)
labetalol
metoprolol

68
Q

When do you prepare for hypotension during pheochromocytoma?

A

with surgical ligation of tumor’s venous drainage causes decreased catechols

69
Q

How do you control hypotension in pheochromocytoma

A

stop anti-hypersensitives
decrease concentration inhalation agent
volume first (crystalloids/ colloids)
administer pressors (phenyl, ne, dopa)
combined RA/GA decrease Hypotension (adequate volume preoperatively)
persistent hypotension may require an infusion of NE until the vasculature can adapt to decrease levels alpha stimulation

70
Q

What drugs do you avoid in pheochromocytoma?

A 
histamien release (morphine, atracurium)
halothane
succinylcholine (fasciculations of abdominal muscle wall may cause catecholamine release)
pancuronium or atropine
metoclopramide
71
Q

What are postoperative considerations for pheochromocytoma?

A 
analgesia (CLE, PCA, opioids)
50% of patients will remain hypertensive 
-elevated catecholamines levels for 10 days postoperatively
continue antihypertensive therapy
early extubation 
hypoglycemia
steroid supplementation
postoperative HTN
adequate pain control
72
Q

Why can you have hypoglycemia postoperative for pheochromocytoma?

A

excess insulin release and ineffective lipolysis and glyconeolysis

N935 Pathophysiology (6 decks)

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