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Flashcards in Endocrine/Cancer Deck (77):
1

Common CA surgeries for men

Prostate (#1)
Lung (#2)
Colon/GI

2

Most common CA surgery for women

Breast

3

Common sites of metastases for resection

Brain, liver, spinal cord

4

Considerations for lung CA surgery

1) Potential for massive bleeding during surgery (make sure to type and cross and set up blood warmer)
2) Pulmonary insufficiency after lung tissue resection (will remain intubated after surgery, get a-line to check ABGs)
3) May have associated CAD

5

Considerations for bronchial and neck CA surgery

1) Look at imaging to determine airway management
2) Ask if they have dysphagia or trouble breathing (checking for airway obstruction)
3) We will lack close accessibility to the airway during the case d/t surgical location
4) Expect significant blood loss

6

Considerations for those on chemo/radiation

CBC
Check for peripheral neuropathies (chemo can cause these)

7

Affect of CA and treatment on the heme system

1) Anemia (d/t bone marrow suppression or GI ulceration/bleeding)
2) Neutropenia and thrombocytopenia

8

Recurrent venous thrombus can occur with ___ CA

pancreatic

9

Types of lung cancers and their effects on the body

1) Squamous (25-40% incidence)
- hypercalcemia
2) Adenocarcinoma (35-50%)
- hypercoagulability & osteoarthritis
3) Large cell (10%)
- gynecomastia
4) Small cell (15-24%)
- Ectopic corticotropin secretion
- Excess ADH secretion
- Eaton-Lambert Syndrome (similar disease process to MG--> will affect the type of NMB we use)

10

When may adrenal insufficiency occur?

Adrenal tumor
Corticosteroid therapy

11

What can happen if TPN is abruptly stopped?

Hypoglycemia

12

Effects of malignant involvement of the pericardium

1) Pericardial tamponade (often happens as a result of lung CA)
- Electrical alternans (alternation of QRS complex amplitude or axis between beats- the heart essentially wobbles in the fluid filled pericardium)
- Paroxysmal a-fib or a-flutter

13

Chemo can cause this effect on the heart

Drug induced cardiomyopathy
- LV function may be impaired for up to 3 years post therapy

14

Invasion of the mediastinum can cause

SVC obstruction
- causes venous engorgement above the waist
Dyspnea and airway obstruction

15

Chemo meds that are cardiac toxic

Doxorubicin and Daunorubicin
- Causes CHF in <3%
- Acute cardiomyopathy in 10% (benign, and symptoms resolve in 1-2 months)
- SEVERE cardiomyopathy in 2% (mortality rate of 60% in 3 weeks, and unresponsive to mechanical/drug therapy)
- These meds enhance the myocardial depression caused by anesthetics (acute LV failure can occur with GA up to 2 months post treatment)

16

Chemo meds that are pulm toxic

1) Methotrexate (8% toxicity)
- sudden pulmonary edema (non-cardiogenic)
- progressive inflammation with infiltrates and effusions

2) Bleomycin (dose-related toxicity-- rare if below 150mg/m2)
- Pulm endothelial damage (treat with corticosteroids) --> can result in type I and II cell necrosis and pulm fibrosis (no tx)
- Increased A-a gradient
- Hyperoxic pulmonary injury (Do not give 100% O2*****)--> try to keep sats over 90% with less than 30% FiO2

17

Effects of 5-fluorouracil

Immunosuppression
Leukopenia
Megaloblastic anemia

18

Chemo meds that are renal toxic

Cisplatin (dose dependent)
- Decreased GFR within 3-5 days
- ATN -> ARF -> hemodialysis

How to treat??
- Hydration and mannitol diuresis (may help to protect against the advancement of renal toxicity)

19

Chemo meds that cause encephalopathy

1) High-dose cyclophosphamide (acute delerium)
2) Methotrexate (reversible, but can cause dementia with prolonged use)

20

These meds can cause neuropathies

1) Vinca alkaloids
- peripheral neuropathies
- Autonomic neuropathy (usually reversible)

2) Cisplatin
- dose-dependent damage to the doral root gangia --> large fiber neuropathy

21

What is autonomic neuropathy?

ANS dysfunction d/t DM
- 20-40% of all diabetics have it
- Most affects the CV and GI systems

Causes:
- Ortho hypotension
- Resting tachycardia
- Impotence
- Peripheral neuropathy
- Loss of HR variability
- Gastroparesis
- Cardiac dysrrhythmia
- Altered breathing regulation
- Sudden death syndrome

22

These chemo meds can cause plasma cholinesterase inhibition

Alkylating agents (Cytoxan)
--it will prolong the effect of sux!!

23

Bleomycin/Busulfan/BCNU can cause

Interstitial pneumonitis and fibrosis (3-6%)
- appears as cough, dyspnea, and basilar rales

Treatment:
- Corticosteroids
- Avoid high FiO2
- Use colloids rather than crystalloids

24

Cardiac complications due to doxorubicin/daunorubicin may first appear as

an upper respiratory infection, but with rapidly progress to CHF. Evaluate ventricular function.

Severe cardiomyopathy can occur if 550mg/m2

25

If a CA patient has N/V, you should always treat them as if they have

a full stomach

26

These meds are commonly used to treat N/V in the CA population

Reglan
Zofran
Droperidol

27

Type of pain scale we should use with CA patients

VAS (visual analogue scale)

28

CA airway evaluation

Tracheal compression or deviation?
Dysphagia or difficulty breathing (airway obstruction)
Trach?
One-lung ventilation?

29

CA and IV access

Prior mastectomy?
Remember that if on chemo, they may have poor vasculature/access
- Allow adequate time to get enough access
- Pt will often know where their best access sites are

30

What are we most concerned about with DM?

Making sure they don't become hypoglycemic****

31

Type 1 diabetics usually have a fasting BG of

300-500

32

Type 1 DM will have high ____ and low ___

High glucagon (normally inhibited by insulin)
Low insulin

33

Type 1 DM are prone to these acute events

hypoglycemia and DKA

34

Fasting BG in type II DM is usually

150-300

35

Are type 1 diabetics responsive to oral hypoglycemics?

No

36

Are type II diabetics responsive to insulin therapy?

May or may not be.

DM II is insulin resistant and will have high glucagon levels.

37

Type II diabetics are prone to this acute condition

Hyperglycemic hyperosmolar nonketotic coma

38

Why is an in-depth pre-op exam important for diabetic patients?

Because DM affects every system in the body

39

HgbA1C tests glucose control over the last ___ months

4 months

Glucose stays attached to the Hgb for the life of the RBC (4 months).

40

Test for diabetic stiff joint syndrome

Prayer sign (patient unable to put palms together)
- can indicate difficult airway

41

Diabetics may have stiffness in these joints that we are concerned about

Atlantooccipital, TMJ, and other cervical joints

42

__-__% of pts with IDDM have evidence of limited joint mobility, and ___% of IDDM pts will have difficult laryngoscopy

30-40%
30% (d/t AOJ and laryngeal rigidity)

43

Why should we assess thyroid gland size in DM I pts?

Because they have a 15% incidence having of other autoimmune diseases, like Hashimoto Thyroiditis

44

Anesthesia things we should be thinking about for pts with DM

Neck mobility?
Do we want the pt to take insulin/hypoglycemic on day of surgery?
How often will be monitor BG?
Do we want IV fluids with glucose?
Need insulin drip?
How tight do we want BG control to be?
How will the pt be managed after surgery?

45

S/S of DKA

N/V
Lethargy
Dehydration (look for s/s)
Abdominal pain
Fruity breath
Kussmaul breathing
Coma

46

S/S of Cushing's Disease (hyperadrenocorticism)

HTN (as it been well controlled??)****
CHF (are they on lasix? watch K levels)
Increased blood volume (salt retention and polycythemia)
Sudden weight gain (usually central)
Moon face (thickening of facial fat)
Glucose intolerance (Diabetes- check glucose level, and control with small amounts of insulin -> 1-5units qh)
Oligomenorrhea or amenorrhea
Decreased libido
Skeletal muscle wasting
Depression or insomnia
Electrolyte abnormalities (hypokalemia, hypernatremia, metabolic acidosis)

47

S/S of Addison's disease (hypoadrenocorticism)

Hypotension
Hypovolemia
Increased BUN and osmolarity d/t hypovolemia
Hyperkalemia
Hyponatremia
Hypoglycemia
Muscle weakness
Abd/back pain
Hyperpigmentation in sun-exposed areas

48

What is important to BP control in Addison's disease?

Steroid replacement

49

Recommended steroid (hydrocortisone) dosing for surgery

Minor surgery
- 25 mg

Major surgery
- 25mg once + 100mg continuous infusion over 24 hours
- 100mg Q8 ( dose pre-op, intra-op, and post-op)

50

S/S of Conn's disease (Hyperaldosteronism)

S/S are nonspecific, and many are asymptomatic!! However, is s/s present, they may be

1) HTN d/t sodium and fluid retension
- HA
- DBP 100-125
- May be resistent to treatment****

2) Hypokalemia
- Polyuria, nocturia, muscle cramps and weakness

51

Pheochromocytoma location

Solitary adrenal (80%)
Bilateral adrenal (10%)
Extra-adrenal (10%)-- most will be in the abdomen

95% are found in the abdominal cavity

52

S/S fo pheochromocytoma

MAIN S/S
- HA
- sweating
- Palpitations

Other s/s
- Anxiety
- Tremor
- Pallor
- Chest pain
- Epigastric pain
- Flushing (rare)
- Painless hematuria (rare)

53

How often to pheochromocytoma episodes occur?

Daily to once every few months
Usually last an hour or less

54

Meds given for pheochromocytoma

First give an alpha blocker
- Phenoxybenzamine (alpha 1&2)
- Phentolamine (selective alpha 1)
--> what we will give in the OR as an infusion

THEN give a beta blocker
- Esmolol

55

____ is the hallmark of primary hyperparathyroidism

Hypercalcemia
Serum Calcium > 5.5mEq/L
iCa > 2.5

Serum Calcium > 7.5 is most likely cancer

56

Effects of hypercalcemia

Prolonged PR interval******
Shortened QT interval*****
HTN*****
Muscle weakness
Kidney stones
Pathologic fractures
Somnolescence

57

Medical management of hypercalcemia

1) Saline infusion if symptomatic (150mL/hr)
2) Loop diuretic (Lasix)
3) Bisphosphonates (IV for life-threatening hypercalcemia-- binds to bone and inhibits osteoclasts)
4) Hemodyalisys
5) Mithramycin (inhibits osteoclast activity, but can cause thrombocytopenia, and cause hepatic and renal toxicity)

58

Diagnosis of hypoparathyroidism

Serum Calcium < 4.5
iCa < 2.0

59

S/S of hypoparathyroidism

Depends on the rate of onset of hypocalcemia****

Acute (thyroidectomy)
- NM irritability***
- Positive chvostek and trousseau's sign***
- Airway STRIDOR****
- Restlessness
- Oral parasthesias

Chronic
- Fatigue and muscle cramps
- Prolonged QT
- Lethargy
- Personality changes

60

What is chvostek's sign?

Tapping of the facial nerve in front of the ear, causes contraction of muscles of the eye, mouth, or nose

61

What is trousseau's sign?

Compression of forearm causes spasm of the hand and wrist

62

Hypocalcemia causes NM _____

Excitability

63

Treatment of hypocalcemia

1) Infuse 10mL of 10% Ca gluconate until symptoms of NM irritability dissipate
2) Thiazide diuretics (HCTZ)
- Na depletion with proportional K excretion causes an increased Ca concentration

64

Lab diagnosis of hyperthyroidism

Elevates T3 and T4
Normal or decreased TSH
Thyroid function test

65

S/S of hyperthyroidism

Anxiety
Weight loss
Heat intolerance
Exophthalmos
Goiter
Diarrhea
Diaphoresis
Tachydysrhythmias
Muscle weakness
Fatigue

66

Treatment of hyperthyroidism

1) Beta antagonists (to treat the tachyarrhythmias)
- Propanolol
- Metoprolol
- Atenolol
- Nadolol

2) Antithyroid meds
- Methimazole
- Carbimazole
- Propylthiouracil (PTU)

3) Iodide containing compounds
- Potassium iodide
- Lugol's solution
- Lithium
- Glucocorticoids

67

Lab diagnosis of hypothyroidism

Low T3 and T4

Primary disease (increased TSH)
Secondary disease (normal or decreased TSH)

68

Causes of primary hypothyroidism

1) Destruction of thyroid gland
- Chronic thyroiditis (Hashimoto's)
- Thyroidectomy
- Previous radioiodine therapy
- Irradiation o the neck

2) Deficiency of thyroid hormones
- Anti-thyroid meds
- Excess iodine (inhibits the release of T3&T4)
- Iodine deficiency (inhibits production)

69

Causes of secondary hypothyroidism

CNS dysfunction
1) Hypothalamic dysfunction (deficiency of thyrotropin releasing hormone)
2) Anterior pituitary dysfunction (deficiency of thyrotropin hormone)

70

S/S of hypothyroidism

Decreased metabolic activity (by 50%)
Lethargy
Cold intolerance
Cardiac changes (may be earliest clinical manifestation)
Decrease cortisol (d/t atrophy of the adrenal cortex)

71

Cardiac effects of hypothyroidism

Increased catecholamine circulation
Increased SVR
HTN
Narrow pulse pressure
Bradycardia
Decreased SV, contractility, and CO
CHF may occur occasionally
EKG changes (prolonged PR, QRS, and QT)
Potential for pericardiac effusion
Get an EKG*******

72

Pulm effects of hypothyroidism

1) Need thyroid hormone to produce surfactant
2) Decreased response to hypoxia and hypercapnia

73

Renal effects of hypothyroidism

Excessive release of ADH
- causes hyponatremia and inability to excrete free water

74

Treatment of hypothyroidism

Oral administration of T4
- However, may not be able to tolerate T4 if they have IHD

75

A positive prayer sign indicates

Cervical immobility and possible difficult intubation

76

What is our main concern with Cushing's disease?

HTN- has it been controlled?

77

Main concern with Addison's disease

Hypotension
- Need steroid replacement for control!!