HORMONES

Question 1

Why do we get AM cortisol levels?

Answer 1

because peak plasma concentration between 4 am - 8 am

Question 2

What kind of feedback does HPA axis have

Answer 2

negative feedback

Question 3

What releases CRH +?

Answer 3

Hypothalamus

Question 4

What releases ACTH+?

What releases cortisol?

cortisol is bound to?

Answer 4

Pituitary releases ACTH

Adrenal releases cortisol

Cortisol is highly protein bound

Question 5

Why would your HPA axis wont work?

What causes adrenal insufficiency?

Answer 5

acute setting: hemodynamic instability

Question 6

What are the clinical manifestations of adrenal insufficiency?

What are the laboratory findings?

Answer 6

Question 7

Common clinical manifestations of CIRCI

Answer 7

Common clinical manifestations of CIRCI
• Hypotension

• Unresponsiveness to catecholamine infusion
• Ventilator dependence

Question 8

How to Diagnose CIRCI using ACTH stim test

Answer 8

ACTH stimulation test

• Dosing of IV ACTH is controversial – 250 mcg vs 1 mcg
• Adrenal insufficiency if delta ≤9 mcg/dL after 250 mcg dose

Question 9

A steroid that does not impact ACTH results

Answer 9

Dexamethasone

Question 10

Managemet of CIRCI

take home points

Answer 10

Question 11

What has the highest mineralcorticoid potency is

Answer 11

Fludcortisone

Question 12

What should be on your differential for refractory hypotension?

Answer 12

Adrenal insufficiency esp. if you gave etomidate

Question 13

Adrenal insufficiency and etomidate

Answer 13

Reduction of corticol secretion in etomidate

doesn’t translate to long term outcomes

Question 14

Management of CIRCI w/o septic shock

Answer 14

Taper is not needed for steroid duration <7 days

Question 15

If someone is exposed to <5 mg /day

Answer 15

—> can be
considered not to have a suppression of HPA axis

Question 16

Management for periopertive steroids in patients receiving chronic prednisone 5 mg daily

MINOR SURGERY

Answer 16

Question 17

Management for periopertive steroids in patients receiving chronic prednisone 5 mg daily

MODERATE SURGERY

Answer 17

Question 18

Management for periopertive steroids in patients receiving chronic prednisone 5 mg daily

MAJOR SURGERY

and

Critically ill

Answer 18

Question 19

What is the maximum hydroctortisone treatment can you have if you are in septic shock and steroid naive

Answer 19

200 mg/ daily

• If you have been chronically exposed >200 probably 300

Question 20

Surviving sepsis campaign

How much steroid is recommended

What about random cortisol level

Optimal duration of therapy?

Answer 20

Question 21

What are the adverse effects of glucocorticoids?

Answer 21

• Suppression of the HPA axis
• Hypergylycemia
• Skeletal muscle myopathy
• Leukocytosis / infection
• Infection
• Decrease wound healing
• Psychosis

Question 22

How is insulin delivery affected?

Answer 22

Question 23

What is type 1 diabetes?

What is type 2?

Answer 23

Question 24

Side effects of insulin

Answer 24

• Insulin resistance
  
  • Defined as the daily need for > 100 units of exogenous insulin
  • Acute insulin resistance is associated with trauma from infection or surgery

Question 25

What do you need to know for Sulfonylureas?

Answer 25

Question 26

What is the SE of Metformin? what does it cause?

Answer 26

\* common diabetic preOp \*\*\* metformin should be held. **LACTIC ACID CAN BE SEE**

Question 27

What are the commonly used Sulfonylureas

Answer 27

If the patient has AKI and they have taken Sulfonylureas-- then they are likely to experience hypoglycemia POST-OP

Question 28

T/F **Tighter glucose control in critically ill patients has been independently associated with increased ICU mortality**

Answer 28

true § Some studies show no difference in mortality

Question 29

What is the presentation of **DKA?** **who commonly has it?**

Answer 29

Diabetic ketoacidosis (DKA) * Combination of **hyperglycemia** (BG \>250 mg/dL) + **ketosis** (positiveurine or serum ketones) + **acidosis** (pH \<7.30 with serum bicarbonate \<18 mmol/L and anion gap \>10) if you add depressed mental status then its **SEVERE DKA** they have to gave 3 -- COMMONLY PRESENT WITH TYPE 1

Question 31

What is the presentation of HHS?

Answer 31

hyperglycemia is much higher. often occurs with type 2 dm

Question 32

Management of DKA and HHS

Answer 32

1. Massive amount of fluid resuscitation 2. Insulin IV 3. Electrolyte replacement --\> be careful with potassium the patient may be hyperkalemic at first because they are volume down. --\> REPLACE K if hypokalemic before you start insulin 4. Correction of acidemia--\> **BICARB should not be given.**