Week 14 endocrine and renal

Question 1

CHAPTER 47 → ENDOCRINE

Key Points

1. The major risk of anesthesia in the poorly controlled thyrotoxic patient is thyroid storm, which must be aggressively treated with _______(1), _______(2), and _______(3) drugs.
2. Asymptomatic or mild hypothyroidism does not appear to significantly increase anesthetic risk and is not a contraindication to surgery. Moderate to severe hypothyroidism should be corrected _______(4) surgery to prevent multisystem complications.
3. Patients who have received corticosteroids for more than _______(5) in the past year may have adrenal suppression and should receive supplemental steroids in the perioperative period.
4. Preoperative preparation of the pheochromocytoma patient with _______(6) blockers decreases intraoperative hemodynamic instability.
5. ______(a) manipulation is associated with severe hypertension that should be treated aggressively with _______(7), phentolamine, or other rapidly acting vasodilators.
6. The major perioperative risks to the diabetic patient come from coexisting disease, especially _______(8) disease. Coexisting disease must be aggressively sought and optimized.
7. Very tight control of perioperative blood glucose levels appears to ______(b) the risk of hypoglycemic complications without clearly reducing the risk of _______(9) complications.
8. ______(c) may be unpredictably difficult in patients with _______(10).

Answer 1

Answers:

1. β-blockers
2. iodide
3. antithyroid
4. before
5. 1 week
6. α
   a. Pheochromocytoma
7. nitroprusside
8. coronary artery
   b. increase
9. hyperglycemia
   c. Endotracheal intubation
10. acromegaly

Question 2

Thyroid Gland

• The thyroid gland secretes thyroid hormones, _______(1) and _______(2), which are the major regulators of cellular metabolic activity.

Thyroid Metabolism and Function

• The production of thyroid hormone is initiated by the active uptake and concentration of iodide in the _______(3).
• Dietary iodine is reduced to iodide in the _______(4) tract.
• Circulating iodide is taken up by the thyroid gland, where it is then bound to tyrosine residues to form various iodothyrosine.
• After organification, monoiodotyrosine or diiodotyrosine is coupled enzymatically by _______(5) to form either T3 or T4.
  
  • These hormones are attached to the thyroglobulin protein and stored as _______(6) in the gland.
  • The release of T3 and T4 from the gland is accomplished through proteolysis from the thyroglobulin and diffusion into the circulation.

Answer 2

Answers:

1. thyroxine (T4)
2. 3,3’,5-triiodothyronine (T3)
3. thyroid gland
4. gastrointestinal (GI)
5. thyroid peroxidase
6. colloid

Question 3

• Thyrotropin (thyroid-stimulating hormone [TSH]) is _______(1) in the anterior pituitary gland, and its secretion is regulated by _______(2) hormone produced in the _______(3).
• TSH is responsible for maintaining the uptake of iodide and proteolytic release of thyroid hormone.
• Excess iodide inhibits the synthesis and secretion of thyroid hormone.
• Circulating thyroid hormone inhibits thyrotropin-releasing hormone and TSH secretion in a _______(4).
• The thyroid gland is solely responsible for the daily secretion of _______(5) (80 to 100 µg/day).
• The half-life of T4 in the circulation is about _______(6).
• Approximately _______(7) of T3 is produced by the extrathyroidal deiodination of T4 and _______(8) is produced by direct thyroid secretion.
  
  • The half-life of T3 is _______(9).
• Most of the effects of thyroid hormones are mediated by the more potent and less protein-bound T3.
• The degree to which these hormones are protein bound in the circulation is the major factor influencing their activity and degradation.
• T4 is metabolized by _______(10) to either T3 or reverse T3 (rT3).
• Changes in serum-binding protein concentrations have a major effect on total T3 and T4 serum concentrations.
• The plasma normally contains _______(11) of T4 and _______(12) of T3.
• Many drugs can affect thyroid function, including _______(13) and _______(14).
  
  • Both medications cause hypothyroidism

Answer 3

Answers:

1. produced
2. thyrotropin-releasing
3. hypothalamus
4. negative-feedback loop
5. T4
6. 7 days
7. 80%
8. 20%
9. 24 to 30 hours
10. monodeiodination
11. 5 to 12 µg/dL
12. 60 to 180 ng/dL
13. amiodarone
14. dopamine

Question 4

Tests of Thyroid Function

• Serum Thyroxine
  
  • The serum T4 assay is a standard test for evaluation of _______(1) function.
• Serum Triiodothyronine
  
  • The serum T3 is also measured by RIA. Serum T3 levels are often determined to detect disease in patients with clinical evidence of _______(2) in the absence of elevations of T4.
• Tests for Assessing Thyroid Hormone Binding
  
  • Because conventional assays measure total hormone levels, which can be affected by _______(3) without affecting free hormone levels, it is necessary for thyroid-binding proteins to correctly interpret total thyroxine levels.

Table 47-1 → Tests of Thyroid Gland Function

STUDY

Answer 4

Answers:

1. thyroid gland
2. hyperthyroidism
3. protein binding

Question 5

Thyroid-stimulating Hormone

• The RIA for thyroid-stimulating hormone is sensitive and specific enough to become the first _______(1) in evaluating suspected _______(2).
• It is often higher than _______(3) in primary hypothyroidism (normal _______(4) to _______(5) µIU/mL).

Radioactive Iodine Uptake

• The thyroid gland has the ability to concentrate large amounts of inorganic iodide.
• The oral administration of radioactive iodine can be used to indicate thyroid gland activity.
• Thyroid uptake is _______(6) in hyperthyroidism unless the hyperthyroidism is caused by _______(7), in which case the uptake is low or absent.

Answer 5

Answers:

1. test
2. thyroid dysfunction
3. 20 µIU/mL
4. 0.4
5. 4.5
6. elevated
7. thyroiditis

Question 6

Hyperthyroidism

• Hyperthyroidism results from the exposure of tissues to excessive amounts of thyroid hormone.
• The most common cause is the _______(1) disease.
  
  • This typically occurs between the ages of _______(2) and _______(3) years and is predominant in women.
  • Most patients with this condition demonstrate a syndrome characterized by diffuse glandular enlargement, ophthalmopathy, dermopathy, and clubbing of the fingers.
• Thyroid _______(4) is the second most common cause.
• Another cause of increased thyroid hormone synthesis is thyroiditis.
  
  • Do you expect high or low radioactive iodine uptake? _______(5) or absent
• Subacute thyroiditis frequently follows a respiratory illness and is characterized by a viral-like illness with a firm, painful gland.
  
  • This type of thyroiditis is frequently treated with _______(6) agents alone.
• Hashimoto thyroiditis is a _______(7) autoimmune disease that usually produces hypothyroidism but may occasionally produce hyperthyroidism.
• Iatrogenic hyperthyroidism may follow thyroid hormone replacement or may occur after iodide exposure (angiographic contrast media) in patients with chronically low iodide intake (_______(8) phenomenon).
• The antiarrhythmic agent _______(9) is iodine rich and is another cause of iodine induced thyrotoxicosis

Table 47-2 → Causes of Hyperthyroidism

Intrinsic thyroid disease
- Hyperfunctioning thyroid adenoma
- Toxic multinodular goiter
Abnormal TSH stimulator
- Graves disease
- Trophoblastic tumor

Disorders of hormone storage or release
- Thyroiditis

Excess production of thyroid-stimulating hormone
- Pituitary thyrotropin (rare)

Extrathyroidal source of hormone
- Struma ovarii
- Functioning follicular carcinoma

Exogenous thyroid
- Iatrogenic
- Iodine induced

TSH, thyroid-stimulating hormone.

Answer 6

Answers:

1. multinodular goiter of Graves
2. 20
3. 40
4. adenoma
5. low
6. anti-inflammatory
7. chronic
8. Jod-Basedow
9. amiodarone

Question 7

Treatment and Anesthetic Considerations

• The most important goal in managing the hyperthyroid patient is to make the patient _______(1) before any surgery, if possible.
• The drugs ______(a) are thiourea derivatives that inhibit organification of iodide and the synthesis of thyroid hormone.
  
  • _____(b) also decreases the peripheral conversion of T4 to _______(2).
• β-Adrenergic antagonists are effective in attenuating the manifestations of excessive sympathetic activity and should be used in all hyperthyroid patients unless contraindicated.
• β-Adrenergic blockade alone does not inhibit hormone synthesis, but specifically _______(3) does impair the peripheral conversion of T4 to T3 over 1 to 2 weeks.
  
  • _______(4) given over 12 to 24 hours decreases tachycardia, heat intolerance, anxiety, and tremor.
• Any β-blocker may be used, and long-acting agents are more convenient.
• The combination of _______(5) (in doses titrated to effect) plus _______(6) (2 to 5 drops every 8 hours) is frequently used before surgery to ameliorate cardiovascular symptoms and reduce circulating concentrations of T4 and T3.
  
  • Preoperative preparation usually requires 7 to _______(7) days.
• All antithyroid medications are ______(c) the morning of surgery.

Answer 7

Answers:

1. euthyroid
   a. propylthiouracil and methimazole
   b. Propylthiouracil
2. T3
3. propranolol
4. Propranolol
5. propranolol
6. potassium iodide
7. 14
   c. continued through

Question 8

• All antithyroid medications are continued through the morning of surgery.
• The goal of intraoperative management in the hyperthyroid patient is to achieve a depth of anesthesia that prevents an exaggerated sympathetic response to surgical stimulation while avoiding the administration of medication that stimulates the sympathetic nervous system.
  
  • _______(1) should be avoided for muscle relaxation due to its _______(2) effects → _______(3).
• It is best to avoid using _______(4) for induction, even when a patient is clinically euthyroid.
• Hypotension that occurs during surgery is best treated with _______(5) rather than a medication that provokes the release of catecholamines.
  
  • Example
  • _______(6)
  • _______(7)
• The incidence of myasthenia gravis is ______(a) in hyperthyroid patients; thus, the initial dose of muscle relaxant should be reduced and a twitch monitor should be used to titrate subsequent doses.
• _______(8) is an excellent alternative when appropriate; however, _______(9)-containing solutions should be avoided.

Answer 8

Answers:

1. Pancuronium
2. vagolytic
3. tachycardia
4. ketamine
5. direct acting vasopressors
6. Neosynephrine
7. Vasopressin
   a. increased
8. Regional anesthesia
9. epinephrine

Question 9

Thyroid Storm

• Thyroid storm is a life-threatening exacerbation of hyperthyroidism that most commonly develops in the undiagnosed or untreated hyperthyroid patient because of the stress of surgery or _______(1) illness.
• Operating on an acutely hyperthyroid gland may provoke thyroid storm, although this is probably not due to mechanical release of hormone.
• Its manifestations include:
  
  • Hyperthermia
  • Tachycardia
  • Dysrhythmias
  • Myocardial ischemia
  • Congestive heart failure
  • Agitation
  • Confusion.
• It must be distinguished from: What is your differential diagnosis for thyroid storm?
  
  • _______(2)
  • _______(3)
  • _______(4)
• Although free T4 levels are often markedly elevated, _______(5) is diagnostic.
• Treatment involves large doses of _______(6) and supportive measures to control fever and restore intravascular volume.
  
  • It is essential to remove or treat the precipitating event.

Table 47-3 → Management of Thyroid Storm (She read straight from this table)

Answer 9

Answers:

1. nonthyroid
2. Pheochromocytoma
3. Malignant hyperthermia
4. Light anesthesia
5. no laboratory test
6. propylthiouracil

Question 10

Anesthesia for Thyroid Surgery

• Indications include failed medical therapy, underlying cancer, and symptomatic goiter.
• The anesthesiologist must be prepared to manage an unexpected difficult intubation because the incidence of difficult intubation during goiter surgery is _______(1) to _______(2).
• The complications after thyroidectomy include:
  
  • Recurrent laryngeal nerve (RLN) damage
    
    • _______(3) injury is an extremely rare injury and necessitates reintubation.
    • _______(4) nerve injury is more common and is _______(5).
      
      • Unilateral damage to the RLN is characterized by hoarseness and a _______(6) vocal cord, whereas bilateral injury causes _______(7).
      • Ask the patient to say “EEE”
• Tracheal compression secondary to hematoma or tracheomalacia
• Hypoparathyroidism
  
  • Parathyroid glands lie behind the thyroid and are very important for calcium balance in the blood
• Pneumothorax may occur during resection of substernal goiters.
• Hypoparathyroidism secondary to the inadvertent surgical removal of parathyroid glands is most frequently seen after total thyroidectomy.
  
  • The symptoms of hypocalcemia develop within _______(8) to _______(9) hours after surgery
    
    • _______(10) progressing to laryngospasm may be one of the first indications of hypocalcemic tetany.
    • Intravenous (IV) administration of calcium chloride or calcium gluconate is warranted in this situation.
    • _______(11) levels should also be monitored and corrected if low.

Answer 10

Answers:

1. 5%
2. 8%
3. Bilateral
4. Unilateral
5. often transient
6. paralyzed
7. aphonia
8. 24
9. 96
10. Laryngeal stridor
11. Magnesium

Question 11

Hypothyroidism

• Hypothyroidism is a relatively common disease (0.3% to 5% of the adult population) that results from inadequate circulating levels of T4, T3, or both.
• Primary failure of the thyroid gland refers to decreased production of thyroid hormone, despite adequate TSH production, and accounts for 95% of all cases of thyroid dysfunction.

Table 47-4 → Causes of Hypothyroidism

Primary hypothyroidism
- Autoimmune
- Irradiation to the neck
- Previous ^131I therapy
- Surgical removal
- Thyroiditis (Hashimoto disease)
- Severe iodine depletion
- Medications (iodines, propylthiouracil, methimazole)
- Hereditary defects in biosynthesis
- Congenital defects in gland development

Secondary or tertiary hypothyroidism
- Pituitary
- Hypothalamic

Adapted from Petersdorf RG, ed. Harrison’s Principles of Internal Medicine. 10th ed. New York, NY: McGraw-Hill; 1983.

Treatment and Anesthetic Considerations

• Treatment of symptomatic hypothyroidism is with hormone replacement therapy.
• Controversy remains regarding the preoperative anesthetic management of the hypothyroid patient.
• There have been few controlled studies to support the position that most hypothyroid patients are unusually sensitive to anesthetic drugs, have prolonged recovery times, or have a higher incidence of cardiovascular instability or collapse.
• No increase in serious complications in patients with mild or moderate hypothyroidism undergoing general anesthesia has been noted.
• One study noted a higher incidence of intraoperative hypotension and postoperative GI and neuropsychiatric complications in _______(1) and _______(2) hypothyroid patients undergoing noncardiac surgery, but still noted there were no compelling clinical reasons to postpone surgery in these patients.
• _______(3) in severely hypothyroid patients should be postponed when possible until these patients are at least partially treated.
• The management of hypothyroid patients with symptomatic coronary artery disease has been a subject of particular controversy.
• The need for thyroid hormone replacement therapy must be weighed against the risk of precipitating myocardial ischemia.

Answer 11

Answers:

1. mild
2. moderately
3. Surgery

Question 12

Several studies and a literature review found no differences in the frequency of intraoperative or postoperative complications when mild or moderately hypothyroid patients underwent cardiac surgery.
- In symptomatic patients or unstable patients with cardiac ischemia, thyroid replacement should probably be _______(1) until after coronary revascularization.

There appears to be little reason to postpone surgery in patients who have mild or moderate hypothyroidism. However, thyroid replacement therapy is indicated for patients with severe hypothyroidism or myxedema coma and for pregnant patients who are hypothyroid.
- Untreated hypothyroidism in pregnant patients is associated with an increased incidence of spontaneous _______(2) and mental and physical abnormalities in the offspring.

A number of anesthetic medications have been used without difficulty in hypothyroid patients.
- Although ______(a) has been proposed as the ideal induction agents, all IV induction agents have _______(3).

Regional anesthesia is a good choice in the hypothyroid patient, provided the intravascular volume is well maintained.
- Monitoring is directed toward the early recognition of hypotension, congestive heart failure, or hypothermia.
- Scrupulous attention should be paid to maintaining normal body temperature.

Myxedema coma represents a severe form of hypothyroidism characterized by stupor or coma, hypoventilation, hypothermia, hypotension, and hyponatremia.
- This is a medical emergency with a high mortality rate (_______(4) to _______(5)) and, as such, requires _______(6).
- Only lifesaving surgery should proceed in the face of myxedema coma.
- IV thyroid replacement is initiated as soon as the clinical diagnosis is made.
- An IV loading dose of T4 (______(b), _______(7) to _______(8) μg) is given initially and followed by a maintenance dose of T4, _______(9) to _______(10) μg/day intravenously.
- There is also an increased likelihood of acute primary adrenal insufficiency in these patients, and they should receive stress doses of _______(11).
- Steroid replacement continues until normal adrenal function can be confirmed.

Table 47-5 → Management of Myxedema (Read straight from this table)

• Tracheal intubation and controlled ventilation as needed
• Levothyroxine, 200–300 μg IV over 5–10 min initially, and 100 μg IV q24h
• Hydrocortisone, 100 mg IV, then 25 mg IV q6h
• Fluid and electrolyte therapy as indicated by serum electrolytes
• Cover to conserve body heat; no warming blankets

Answer 12

Answers:

1. delayed
2. abortion
   a. ketamine
3. been used in the hypothyroid patient
4. 25%
5. 50%
6. aggressive therapy
   b. sodium levothyroxine
7. 200
8. 300
9. 50
10. 200
11. hydrocortisone

Question 13

Parathyroid Glands - Calcium Physiology
- The normal adult body contains approximately 1 to 2 kg of calcium (Ca2+), of which 99% is in the ______(a).
- Plasma calcium is present in three forms:
- (a) a _______(1) fraction (50%)
- (b) an _______(2) fraction (45%)
- (c) a diffusible but nonionized fraction (5%) that is complexed with phosphate, bicarbonate, and citrate.
- This division is interesting because it is the _______(3) fraction that is physiologically active and homeostatically regulated.
- The normal total serum calcium concentration is _______(4) to _______(5).
- _______(6) binds approximately 90% of the protein-bound fraction of calcium, and total serum Ca2+ consequently depends on _______(7).
- In general, an increase or decrease in albumin of _______(8) is associated with a parallel change in total serum Ca2+ of _______(9).
- The serum ionized Ca2+ concentration is affected by _______(10) and _______(11) through alterations in Ca2+ protein binding to _______(12).
- Acidosis ______(b) protein binding (______(c) ionized Ca2+)
- Alkalosis _______(d) protein binding (______(e) ionized Ca2+).

Answer 13

Answers:
a. skeleton
1. protein-bound
2. ionized
3. ionized
4. 8.8
5. 10.4 mg/dL
6. Albumin
7. albumin levels
8. 1 g/dL
9. 0.8 mg/dL
10. temperature
11. blood pH
12. albumin
b. decreases
c. increases
d. increases
e. decreases

Question 14

• The concentration of free Ca2+ ion is of critical importance in regulating skeletal muscle contraction, coagulation, neurotransmitter release, endocrine secretion, and a variety of other cellular functions.
  
  • As a consequence, the maintenance of serum Ca2+ concentration is subject to tight hormonal control by _______(1) and _______(2).
• PTH secretion is primarily regulated by the _______(3).
  
  • This negative-feedback mechanism is exquisitely sensitive in maintaining calcium levels in a normal range.
  • Release of PTH is also influenced by _______(4), _______(5), and _______(6) levels.
• Vitamin D is absorbed from the _______(7) and can be produced enzymatically by ultraviolet irradiation of the skin.
• Vitamin D (cholecalciferol) is made from _______(8) metabolites and is _______(9).
• Calciferol is _______(10) in the liver to 25-hydroxycholecalciferol (25-OHD) and in the kidney is further _______(11) to 1,25-dihydroxycholecalciferol [1,25(OH)2D] or 24,25-dihydroxycholecalciferol [24,25(OH)2D].
  
  • Which phase does hydroxylation occur? phase _______(12).
• The synthesis of this form is _______(13) by a hormone or by Ca2+ or phosphate levels.
• Hypocalcemia and hypophosphatemia cause an _______(14) production of 1,25(OH)2D and a _______(15) production of 24,25(OH)2D. 1,25(OH)2D stimulates bone, kidney, and intestinal absorption of calcium and phosphate.
• ______(a) deficiency can lead to decreased intestinal absorption of Ca2+ and secondary _______(16).

Answer 14

Answers:

1. parathyroid hormone (PTH)
2. vitamin D
3. serum ionized Ca2+ concentration
4. phosphate
5. magnesium
6. catecholamine
7. GI tract
8. cholesterol
9. inactive
10. hydroxylated
11. hydroxylated
12. I
13. not regulated
14. increased
15. decreased
    a. Vitamin D
16. hyperparathyroidism

Question 15

Hyperparathyroidism

• Primary hyperparathyroidism is most commonly due to a _____(a) (90% of cases) or _______(1) and very rarely to a parathyroid carcinoma.
• Primary hyperparathyroidism may also exist as part of a multiple endocrine neoplastic (MEN) syndrome. Hyperplasia usually involves all four glands.
• Hypercalcemia is responsible for a broad spectrum of signs and symptoms.
  
  • _______(2) is the most common manifestation, occurring in 60% to 70% of patients.
  • Polyuria and polydipsia are also common complaints.
  • An increase in bone turnover may lead to generalized demineralization and subperiosteal bone resorption; however, only a small group of patients (10% to 15%) have clinically significant bone disease.
  • Patients may experience generalized skeletal muscle weakness and fatigability, epigastric discomfort, peptic ulceration, or constipation.
  • Psychiatric manifestations include depression, memory loss, confusion, or psychosis.
  • Between 20% and 50% of patients are _______(3), but this usually resolves with successful treatment of the disease.
  • _____(b) function is enhanced in the early stages of hypercalcemia.
    
    • Calcium flux into the cells is reflected in the _______(4) phase of the action potential (phase 2).
    • As extracellular calcium increases, the inward flux is more rapid, and phase 2 is _______(5).
    • The corresponding ECG change is a _______(6) QT interval.
    • Cardiac contractility may increase until a level between _______(7) and _______(8) is reached.
    • At this point, there is a prolongation of the PR segment and QRS complex that can result in heart block or bundle-branch block.
    • Bradycardia also occurs.

Answer 15

Answers:
a. benign parathyroid adenoma
1. hyperplasia
2. Nephrolithiasis
3. hypertensive
b. Cardiac
4. plateau
5. shortened
6. shorter
7. 15
8. 20 mg/dL

Question 16

• An elevated serum Ca2+ concentration is a valuable diagnostic indicator of primary _______(1).
• Treatment and Anesthetic Considerations
  
  • _______(2) is the treatment of choice for the patient with symptomatic disease.
  • Surgery is often chosen over medical therapy because it offers definitive treatment and is generally safe.
  • Preoperative preparation focuses on the correction of intravascular volume and electrolyte irregularities.
  • It is particularly important to evaluate the patient with chronic hypercalcemia for abnormalities of the renal, cardiac, or central nervous systems.
  • Emergency treatment of hypercalcemia is undertaken before surgery when the serum Ca2+ concentration exceeds _______(3) mg/dL (7.5 mEq/L).
  • Lowering of the serum Ca2+ concentration is initially accomplished by expanding the _______(4) and establishing a _______(5).
    
    • This is achieved with the IV administration of normal saline and _______(6).
    • Rehydration alone is capable of lowering the serum Ca2+ level by at least _______(7) mg/dL.
    • Hydration dilutes the serum Ca2+, and sodium diuresis promotes Ca2+ excretion through an inhibition of sodium and Ca2+ resorption in the _______(8) tubule.
    • Hypokalemia and _______(9) may result.
    • Another element in the treatment of hypercalcemia is the correction of _______(10).
• Hypophosphatemia _______(11) GI absorption of Ca2+, stimulates the _______(12) of bone, and impairs the uptake of Ca2+ by bone.
• Low serum phosphate levels impair cardiac contractility and may contribute to _______(13) failure. Hypophosphatemia also causes skeletal muscle weakness, hemolysis, and _______(14) dysfunction.
• Other medications that have a role in lowering the serum Ca2+ include:
  
  • _______(15)
    
    • Bisphosphonates are pyrophosphate analogs that inhibit ______(a) action.
    • They are the drugs of choice for ______(b) hypercalcemia.
    • Toxic effects include _______(c)

Answer 16

Answers:
1. hyperparathyroidism
2. Surgery
3. 15
4. intravascular volume
5. sodium diuresis
6. furosemide
7. 2
8. proximal
9. hypomagnesemia
10. hypophosphatemia
11. increases
12. breakdown
13. congestive heart
14. platelet
15. Bisphosphonates
a. osteoclast
b. severe
c. fever and hypophosphatemia.

Question 17

• Mithramycin, a _______(1) agent, inhibits PTH induced osteoclast activity and can lower the serum Ca2+ levels by at least _______(2) mg/dL in 24 to 48 hours.
  
  • Toxic effects include _______(3), _______(4), and _______(5).
• Calcitonin
  
  • Calcitonin is useful in transiently lowering the serum Ca2+ level _______(6) to _______(7) mg/dL through direct inhibition of osteoclastic bone resorption.
  • The advantages of calcitonin are the mild side effects (_______(8), _______(9)) and the rapid onset of activity. Calcitonin resistance usually develops within _______(10) to _______(11) hours.
• Glucocorticoids.
  
  • Glucocorticoids are effective in lowering the serum Ca2+ concentration in several conditions (sarcoidosis, some malignancies, hyperthyroidism, vitamin D intoxication) through their actions on osteoclast bone resorption, GI absorption of calcium, and the urinary excretion of calcium.
  • Glucocorticoids are usually of no benefit in the treatment of primary hypercalcemia.
  • Finally, _______(12) or _______(13) can be used to lower the serum Ca2+ level when alternative regimens are ineffective or contraindicated.
• Because of the unpredictable response to neuromuscular-blocking drugs in the hypercalcemic patient, a conservative approach to muscle paralysis makes sense.
  
  • There is an increased requirement for _______(14), and probably all nondepolarizing muscle relaxants, during onset of neuromuscular blockade.

Answer 17

Answers:
1. cytotoxic
2. 2
3. azotemia
4. hepatotoxicity
5. thrombocytopenia
6. 2
7. 4
8. urticaria
9. nausea
10. 24
11. 48
12. hemodialysis
13. peritoneal dialysis
14. vecuronium

Question 18

• Anesthesia for Parathyroid Surgery
  
  • General anesthesia is most commonly used for parathyroid surgery.
  • Minimally invasive parathyroidectomy is superior to conventional bilateral cervical exploration in patients with sporadic primary hyperparathyroidism and can usually be performed under _______(1).
  • Some centers use an intraoperative rapid _______(2) to help determine when a hyperfunctioning gland has been removed.
    
    • A freely back-flowing IV catheter is needed for frequent _______(3).
    • There is in vitro, but no clinical, evidence that propofol can interfere with the _______(4), so many surgeons prefer that propofol not be used within _______(5) of an assay.
• Postoperative complications include RLN injury, bleeding, and transient or complete hypoparathyroidism.
  
  • Unilateral RLN is characterized by _______(6) and usually requires no intervention.
  • Bilateral RLN injury is a rare complication, producing _______(7) and requiring immediate tracheal intubation.
• After successful parathyroidectomy, a decrease in the serum Ca2+ level should be observed within _______(8) hours.

Answer 18

Answers:
1. bilateral cervical plexus block
2. PTH assay
3. sampling
4. assay
5. 15 minutes
6. hoarseness
7. aphonia
8. 24

Question 19

Hypoparathyroidism

• An underproduction of _______(1) or resistance of the end-organ tissues to _______(2) results in hypocalcemia (<8 mg/dL).
• The most common cause of acquired PTH deficiency is unintentional removal of the _______(3) during thyroid or parathyroid surgery.
• These patients are commonly treated with _______(4), which increases intestinal calcium absorption and suppresses secondary increases in PTH secretion.
• Clinical Features and Treatment
  
  • The clinical features of hypoparathyroidism are a manifestation of hypocalcemia.
    
    • Neuronal irritability and skeletal muscle spasms, tetany, or seizures reflect a reduced threshold of excitement.
    • Latent tetany may be demonstrated by eliciting the _______(5) or _______(6) sign.
      
      • A _______(7) sign is a contracture of the facial muscle produced by tapping the facial nerve as it passes through the parotid gland.
      • A _______(8) sign is a contracture of the fingers and wrist after application of a blood pressure cuff inflated above the systolic blood pressure for approximately 3 minutes.
• Other common complaints of hypocalcemia include fatigue, depression, paresthesias, and skeletal muscle cramps.

Answer 19

Answers:
1. PTH
2. PTH
3. parathyroid glands
4. vitamin D
5. Chvostek
6. Trousseau
7. Chvostek
8. Trousseau

Question 20

• The acute onset of hypocalcemia after thyroid or parathyroid surgery may manifest as _______(a).
• The treatment of hypoparathyroidism consists of electrolyte replacement.
  
  • The objective is to have the patient’s clinical symptoms under control before anesthesia and _______(1).
  • Hypocalcemia caused by magnesium depletion is treated by correcting the _______(2) deficit.
  • Serum phosphate excess is corrected by the removal of phosphate from the diet and the oral administration of (_______(3)).
  • The urinary excretion of phosphate can be increased with a _______(4) infusion. Ca2+ deficiencies are corrected with Ca2+ supplements or vitamin _______(5) analogs.
• Patients with severe symptomatic hypocalcemia are treated with IV calcium gluconate (_______(6) to _______(7) of 10% solution) given over several minutes and followed by a continuous infusion (_______(8) to _______(9) of elemental Ca2+).

Answer 20

Answers:
a. stridor and apnea
1. surgery
2. magnesium
3. phosphate-binding resins (aluminum hydroxide)
4. saline volume
5. D
6. 10
7. 20 mL
8. 1
9. 2 mg/kg/hr

Question 21

Adrenal Cortex
- The adrenal cortex functions to synthesize and secrete three types of hormones.
- 1. Endogenous and dietary cholesterol is used in the adrenal biosynthesis of _______(1) (cortisol)
- 2. Mineralocorticoids (_______(2) and 1_____(a))
- 3. Androgens (_______(3)).
- Abnormal function of the adrenal cortex may render a patient unable to respond appropriately during a period of surgical stress or critical illness.

Glucocorticoid Physiology
- _______(4) (hydrocortisone) is the most potent endogenous glucocorticoid and is produced by the ______(b) portions of the _______(5).
- _______(6) has multiple effects on intermediate carbohydrate, protein, and fatty acid metabolism, as well as maintenance and regulation of immune and circulatory function.

Answer 21

Answers:
1. glucocorticoids
2. aldosterone
a. 1-deoxycorticosterone
3. dehydroepiandrosterone
4. Cortisol
b. inner
5. adrenal cortex
6. Cortisol

Question 22

Mineralocorticoid Physiology
- _______(1) is the most potent mineralocorticoid produced by the adrenal gland.
- _______(2) is a major regulator of extracellular volume and potassium homeostasis through the resorption of sodium and the secretion of potassium by these tissues.
- The major regulators of aldosterone release are the _______(3) and serum potassium levels (Fig. 47-3).

• The _______(4) that surrounds the renal afferent arterioles produces renin in response to decreased perfusion pressures and sympathetic stimulation.
• _______(5) is the most potent vasopressor produced in the body. It directly stimulates the adrenal cortex to produce aldosterone.
• The renin–angiotensin system is the body’s most important protector of _______(6).

Answer 22

Answers:
1. Aldosterone
2. Aldosterone
3. renin–angiotensin system
4. juxtaglomerular apparatus
5. Angiotensin II
6. volume status

Question 23

Anesthetic Management
- General considerations for the preoperative preparation of the patient include treating hypertension, diabetes, and normalizing intravascular fluid volume and electrolyte concentrations.
- Diuresis with the aldosterone antagonist _______(1) helps mobilize fluid and normalize potassium concentration.
- When either unilateral or bilateral adrenalectomy is planned, glucocorticoid replacement therapy is initiated at a dose equal to full replacement of adrenal output during periods of extreme stress.
- The total dosage is reduced by approximately 50% per day until a daily maintenance dose of steroids is achieved (_______(2) to _______(3) mg/day).
- Hydrocortisone given in doses of this magnitude exerts significant mineralocorticoid activity, and additional exogenous mineralocorticoid is usually not necessary during the perioperative period.
- After bilateral adrenalectomy, most patients require _______(4) to _______(5) mg/day of fludrocortisone (9-α- fluoro hydrocortisone) starting around day 5 to provide mineralocorticoid activity.
- Slightly higher doses may be needed if _______(6) is used for glucocorticoid maintenance because it has little intrinsic mineralocorticoid activity.
- The fludrocortisone dose is ______(a) if congestive heart failure, hypokalemia, or hypertension develops.
- When significant skeletal muscle weakness is present, a conservative approach to the use of muscle relaxants is warranted.
- _______(7) has been used for temporary medical treatment of severe Cushing syndrome because of its inhibition of steroid synthesis.

Answer 23

Answers:
1. spironolactone
2. 20
3. 30
4. 0.05
5. 0.1
6. prednisone
a. reduced
7. Etomidate

Question 24

Glucocorticoid Excess (Cushing Syndrome)
- Cushing syndrome, caused by either overproduction of cortisol by the adrenal cortex or exogenous glucocorticoid therapy, is a syndrome characterized by:
- Truncal _______(1)
- _______(2)
- Hyperglycemia
- ______(a) intravascular fluid volume
- _______(3)
- Fatigability
- Abdominal _______(4)
- _______(5)
- Muscle weakness

• Most cases of Cushing syndrome that occur spontaneously are due to bilateral adrenal _______(6) secondary to ACTH produced by an anterior pituitary microadenoma or non-endocrine tumor (e.g., of the _______(7), _______(8), or pancreas).
• The primary overproduction of cortisol and other adrenal steroids is caused by an adrenal neoplasm in approximately 20% to 25% of patients with Cushing syndrome.
• Finally, an increasingly common cause of Cushing syndrome is the prolonged administration of exogenous _______(9) to treat a variety of illnesses.
• The signs and symptoms of Cushing syndrome follow from the known actions of glucocorticoids.
  
  • Truncal obesity and thin extremities reflect increased muscle wasting and a redistribution of fat in facial, cervical, and truncal areas. ______(b) calcium absorption and a decrease in bone formation may result in osteopenia.
  • Sixty percent of patients have ______(c), but overt diabetes mellitus (DM) occurs in less than 20%.

Answer 24

Answers:
1. obesity
2. Hypertension
a. Increased
3. Hypokalemia
4. striae
5. Osteoporosis
6. hyperplasia
7. lung
8. kidney
9. glucocorticoids
b. Impaired
c. hyperglycemia

Question 25

Mineralocorticoid Excess
- Hypersecretion of the major adrenal mineralocorticoid aldosterone increases the renal tubular exchange of sodium for _______(1) and _______(2) ions.
- This leads to hypertension, _______(3), alkalosis, skeletal muscle weakness, and fatigue.
- Patients with primary hyperaldosteronism (Conn syndrome) characteristically do not have _______(4).
- Secondary aldosteronism results from an elevation in _______(5) production.
- The diagnosis of primary or secondary hyperaldosteronism should be entertained in the nonedematous hypertensive patient with persistent hypokalemia who is not receiving potassium-wasting diuretics.

Anesthetic Considerations
- Preoperative preparation for the patient with primary aldosteronism is directed toward restoring the intravascular volume and the electrolyte concentrations to normal.
- Whenever possible, potassium should be replaced _______(6) to allow equilibration between intracellular and extracellular potassium stores.
- The usual complications of chronic hypertension need to be assessed.

Answer 25

Answers:
1. potassium
2. hydrogen
3. hypokalemia
4. edema
5. renin
6. slowly

Question 26

Adrenal Insufficiency (Addison’s Disease)
- The _______(1) of adrenal steroid hormones may develop as the result of a primary inability of the adrenal gland to elaborate sufficient quantities of hormone or as the result of a deficiency in the production of ACTH.
- Clinically, primary adrenal insufficiency is usually not apparent until at least _______(2) of the adrenal cortex has been destroyed.
- The predominant cause of primary adrenal insufficiency used to be _______(3); however, today, the most frequent cause of Addison disease is _______(4) adrenal insufficiency secondary to autoimmune destruction of the gland.
- Autoimmune destruction of the adrenal cortex causes both a _______(5) and a _______(6) deficiency.
- A variety of other conditions presumed to have an autoimmune pathogenesis may also occur concomitantly with idiopathic Addison disease.
- _______(7) in association with autoimmune adrenal insufficiency is termed Schmidt syndrome.
- Other possible causes of adrenal gland destruction include certain bacterial, fungal, and advanced human immunodeficiency virus infections; metastatic cancer; sepsis; and hemorrhage.

Answer 26

Answers:
1. undersecretion
2. 90%
3. tuberculosis
4. idiopathic
5. glucocorticoid
6. mineralocorticoid
7. Hashimoto thyroiditis

Question 27

Clinical Presentation
- The cardinal symptoms of idiopathic Addison disease include:
- Chronic fatigue
- Muscle weakness
- Anorexia
- Weight loss
- Nausea, vomiting, and diarrhea.
- _______(1) is almost always encountered in the disease process.

• Female patients may exhibit decreased _______(2) and _______(3) hair growth because of the loss of adrenal androgen secretion.
• An acute crisis can present as:
  
  • Abdominal pain
  • ______(a) vomiting and diarrhea
  • Hypotension
  • _____(b) consciousness
  • Shock.
• _______(4) may be a cause of life-threatening cardiac dysrhythmias.

Answer 27

Answers:
1. Hypotension
2. axillary
3. pubic
a. Severe
b. Decreased
4. Hyperkalemia

Question 28

Diagnosis
- The patient’s pituitary–adrenal responsiveness should be determined when the diagnosis of primary or secondary adrenal insufficiency is first suspected.
- Biochemical evidence of impaired adrenal or pituitary secretory reserve unequivocally confirms the diagnosis. Patients who are clinically stable may undergo testing before treatment is initiated. Those believed to have acute adrenal insufficiency should receive immediate therapy.
- Plasma cortisol levels are measured before and _______(1) minutes after the IV administration of _______(2) µg of synthetic ACTH. There are multiple determinants for adequate adrenal reserve; usually the plasma cortisol rises at least 500 nmol/L _______(3) minutes after the injection of the synthetic ACTH.35
- Patients with adrenal insufficiency usually demonstrate little or no adrenal response.

Treatment and Anesthetic Considerations
- Normal adults secrete about _______(4) mg of cortisol (hydrocortisone) and _______(5) mg of aldosterone per day.
- Glucocorticoid therapy is usually given twice daily in sufficient dosage to meet _______(6) requirements.
- A typical regimen in the unstressed patient may consist of prednisone, _______(7) mg in the morning and _______(8) mg in the evening, or hydrocortisone, _______(9) mg in the morning and _______(10) mg in the evening.

Answer 28

Answers:
1. 30 and 60
2. 250
3. 60
4. 20
5. 0.1
6. physiologic
7. 5
8. 2.5
9. 20
10. 10

Question 29

Table 47-6 – Management of Acute Adrenal Insufficiency
- Hydrocortisone, _______(1) mg IV bolus, followed by hydrocortisone, _______(2) mg q6h for 24 h
- Fluid and electrolyte replacement as indicated by vital signs, serum electrolytes, and serum glucose

Steroid Replacement During the Perioperative Period
- A low dose cortisol replacement program using an IV infusion of _______(3) mg of cortisol before the induction of anesthesia, followed by a continuous infusion of cortisol (_______(4) mg) in the next 24 hours, has been advocated (Fig. 47-4)

Table 47-7 – Management Options for Steroid Replacement in the Perioperative Period (Read straight from this chart)
- Hydrocortisone, _______(5) mg IV, at the time of induction followed by hydrocortisone infusion, _______(6) mg over 24 h
- Hydrocortisone, _______(7) mg IV, before, during, and after surgery

Answer 29

Answers:
1. 100
2. 100
3. 25
4. 100
5. 25
6. 100
7. 100

Question 30

Table 47-8 – Glucocorticoid Preparations (Read straight from this chart, which are short, intermediate, long acting)

Short-acting:
- Hydrocortisone: Anti-inflammatory – 1.0, Mineralocorticoid – 1.0, Approximate Equivalent Dose (mg) – _______(1)
- Cortisone: Anti-inflammatory – 0.8, Mineralocorticoid – 0.8, Approximate Equivalent Dose (mg) – _______(2)

Intermediate-acting:
- Triamcinolone: Anti-inflammatory – 5.0, Mineralocorticoid – None, Approximate Equivalent Dose (mg) – _______(3)

Long-acting:
- Dexamethasone: Anti-inflammatory – 30.0, Mineralocorticoid – None, Approximate Equivalent Dose (mg) – _______(4)

Mineralocorticoid Insufficiency
- This syndrome is commonly seen in patients with mild _______(5) failure and longstanding _______(6). A feature common to all patients with hypoaldosteronism is a failure to increase aldosterone production in response to ______(a) restriction or _______(7) contraction.

Answer 30

Answers:
1. 20.0
2. 25.0
3. 4.0
4. 0.75
5. renal
6. DM (diabetes mellitus)
a. salt
7. volume

Question 31

Pheochromocytoma
- The only important endocrine disease process associated with the adrenal _______(1) is pheochromocytoma.
- These tumors produce, store, and secrete catecholamines.
- _______(2) are tumors that arise from autonomic ganglia and behave pathophysiologically like pheochromocytomas.
- Most pheochromocytomas secrete both _______(3) and _______(4), with the fraction of secreted _______(5) being greater than that secreted by the normal gland.
- Although pheochromocytomas occur in less than 0.2% of hypertensive patients, it is important to aggressively evaluate the patient with clinically suspect symptoms because surgical extirpation is curative in over 90% of patients and complications are often lethal in undiagnosed cases.
- Most deaths are from _______(6) causes.
- Perioperative morbidity is related to tumor _______(7) and the degree of catecholamine secretion.
- Most (85% to 90%) pheochromocytomas are solitary tumors localized to a single adrenal gland, usually the _______(8).

Answer 31

Answers:
1. medulla
2. Paragangliomas
3. epinephrine
4. norepinephrine
5. norepinephrine
6. cardiovascular
7. size
8. right

Question 32

Pheochromocytoma

• Approximately 10% of adults and 25% of children have bilateral _______(1).
• Malignant spread of these highly vascular tumors occurs in approximately 10% of cases.
• Pheochromocytoma may occur at any age, but it is most common in young to middle _______(2) life.
• The clinical manifestations are mainly due to the pharmacologic effects of the _______(3) released from the tumor.
• Most patients have sustained _______(4), although occasionally it is paroxysmal.
  
  • When true paroxysms occur, the blood pressure may rise to alarmingly high levels, placing the patient at risk for cerebrovascular hemorrhage, heart failure, dysrhythmias, or myocardial _______(5).
• Headache, palpitations, tremor, profuse sweating, and either pallor or flushing may accompany an _______(6).
• Pheochromocytoma can masquerade as _______(7).

Answer 32

Answers:
1. tumors
2. adult
3. catecholamines
4. hypertension
5. infarction
6. attack
7. malignant hyperthermia

Question 33

Diagnosis

• Biochemical determination of free catecholamine and catecholamine metabolites in the _______(1) is the most common screening test used to establish the diagnosis of pheochromocytoma.
• Urinary _______(2) and unconjugated ______(a) levels are measured in a 24-hour urine collection and are expressed as a function of the creatinine clearance.
• Excess production of catecholamines is diagnostic for pheochromocytoma.

Anesthetic Considerations
- Perioperative mortality rates have decreased from a high of 45% to between 0% and 3% for excision of pheochromocytoma followed by the introduction of _______(3) for preoperative therapy.
- Perioperative blood pressure fluctuations, myocardial infarction, congestive heart failure, cardiac dysrhythmias, and cerebral hemorrhage all appear to be reduced in frequency when the patient has been treated before surgery with _______(4) and the intravascular fluid compartment has been re-expanded.
- Extended treatment with α-antagonists is also effective in treating the clinical manifestations of catecholamine myocarditis.
- _______(5) is initiated once the diagnosis of pheochromocytoma is established.
- ______(b), a long-acting (24 to 48 hours), noncompetitive presynaptic (α2) and postsynaptic (α1) blocker, has traditionally been used at doses of _______(6) mg every 8 hours.
- Increments are added until the blood pressure is controlled and paroxysms disappear.
- Most patients need between ______(c) mg/day.
- The absorption after oral administration is variable, and side effects are common.
- Certain cardiovascular reflexes such as the _______(7) are blunted, and postural ______(d) is common.

Answer 33

Answers:
1. urine
2. vanillylmandelic acid
a. norepinephrine and epinephrine
3. α-antagonists
4. α-blockers
5. α-Adrenergic blockade
b. Phenoxybenzamine
6. 10
c. 80 and 200
7. baroreceptor reflex
d. hypotension

Question 34

Anesthetic Considerations

• Selective competitive α1-blockers, such as ______(a), can also be used effectively with fewer side effects.
• Although the optimal period of preoperative treatment has not been established, most clinicians recommend beginning ______(b) at least _______(1) before the proposed surgery; however, periods as short as _______(2) have been used.
• β-Adrenergic blockade is occasionally added ______(c) α-blockade has been established.
• This addition is considered in patients with persistent tachycardia or cardiac dysrhythmias that may be caused by nonselective α-blockade or epinephrine-secreting tumors.
• _______(3) should not be given until adequate ______(d) is ensured to avoid the possibility of ______(e).
• There is no clear preoperative advantage of one β-antagonist over another, although the short half-life of _______(4) may allow better control of heart rate and arrhythmias in the perioperative setting.
  
  • Why? → short half-life; once tumor is removed, don’t want a drug that is going to linger once cause is gone.
• _______(5), a β-adrenergic antagonist with α-blocking activity, is effective as a second-line medication, but can increase blood pressure when used alone.

Answer 34

Answers:
a. doxazosin, terazosin, and prazosin
b. α-blockade therapy
1. 10 to 14 days
2. 3 to 5 days
c. after
3. β-Blockers
d. α-blockade
e. unopposed α-mediated vasoconstriction
4. esmolol
5. Labetalol

Question 35

Anesthetic Considerations

• Symptomatic patients continue to receive medical therapy until tachycardia, cardiac dysrhythmias, and paroxysmal elevations in blood pressure are well controlled.
  
  • If it is not possible to initiate α-blocking therapy before surgery or if the patient has received less than 48 hours of intensive treatment, it may be necessary to infuse _______(1) during the induction of anesthesia.
  • A low dose infusion is often initiated in anticipation of the marked blood pressure elevations that can occur with laryngoscopy and surgical stimulation.
• During laparoscopic surgery, creation of the ______(a) may cause release of catecholamines and large changes in hemodynamics that can be controlled with a vasodilator.
• Continuous intra-arterial blood pressure monitoring is required for managing the patient with pheochromocytoma.
• Although there is no clear advantage to one anesthetic technique over another, drugs that are known to liberate histamine are avoided.
  
  • Certain induction meds too? atracurium for example
  • ______(b) such as droperidol and metoclopramide can provoke catecholamine release and should not be used.
  • A potent sedative hypnotic, in combination with an opioid analgesic, is used for induction.
  • It is extremely important to achieve an adequate depth of anesthesia before proceeding with laryngoscopy to minimize the sympathetic nervous system response to this maneuver.
• Maintenance is provided with an opioid analgesic and a potent inhalation agent.

Answer 35

Answers:
1. nitroprusside
a. pneumoperitoneum
b. Dopamine antagonists

Question 36

Anesthetic Considerations

• Manipulation of the tumor may produce a marked elevation in blood pressure. Acute hypertensive crises are treated with IV infusions of _______(1) or _______(2) (both considered short acting) or any vasodilator mentioned later.
  
  • Phentolamine is a short-acting α-adrenergic antagonist that may be given as an IV bolus (2 to 5 mg) or by continuous infusion.
  • Tachydysrhythmia is controlled with IV boluses of _______(3) (1-mg increments) or by a continuous infusion of the ultrashort-acting selective β1-adrenergic antagonist _______(4).
  • The disadvantage of long-acting β-blockers may be persistence of bradycardia and hypotension after the tumor is removed.
  • Even esmolol may be problematic because there are cases of cardiac arrest after clamping of the venous drainage in patients receiving large doses of esmolol.
• After surgery, catecholamine levels return to normal over several days.
• Approximately 75% of patients become normotensive within _______(5) days.
• ______(a) must be watched for as insulin levels rise from loss of catecholamine-induced β-cell suppression.

Table 47-9 → Drugs Used in the Management of Pheochromocytoma

STUDY

Answer 36

Answers:
1. nitroprusside
2. phentolamine
3. propranolol
4. esmolol
5. 10
a. Hypoglycemia

Question 37

Understanding Diabetes Mellitus

• A fasting glucose level below _______(1) mg/dL is considered normal.
• Individuals with documented fasting glucose levels above _______(2) mg/dL (HbA1c ≥_______(3)%) are considered diabetics.
• Those with levels between _______(4) mg/dL (HbA1c 5.7 to 6.4) are considered prediabetics.
• Diabetes Mellitus (DM) primarily manifests as a disease of glucose metabolism; however, it significantly affects lipid and protein metabolism and has an impact on a wide range of endocrinologic functions.
• Despite a variety of etiologic factors, its hallmark is a deficiency, either absolute or relative, in the amount of insulin effect to the tissues.
• DM is classified into four broad types:
  
  • Type 1 diabetes
    
    • Type 1 is due to pancreatic ______(b) destruction, usually leading to absolute insulin deficiency.
    • It accounts for 5% to 10% of all DM cases and is distinguished from type 2, which accounts for the remaining 90% to 95% of all DM cases.
    • Most patients with type _______(5) DM typically experience the onset of disease early in life.
    • It is difficult to maintain an optimal glucose level in patients with type _______(6) DM.

Answer 37

Answers:
1. 100
2. 126
3. 6.5
4. 100 and 125
a. 5.7 to 6.4
b. β-cell
5. 1
6. 1

Question 38

Characteristics of Diabetes Types

• Type ______(a) diabetes
  
  • Individuals with type ______(b) diabetes are more likely to become ketotic and sustain progressive end-organ complications of diabetes.
  • Classification is important for determining therapy. Hyperglycemia in patients with type ______(1) diabetes cannot be controlled with diet or oral hypoglycemic agents; rather, it mandates treatment with insulin as there is an absolute deficiency of _______(1).
• Type 2 diabetes
  
  • Patients with type 2 DM, also called ______(d)-onset diabetes, typically experience a gradual onset of the disease later in life.
  • It is due to a progressive loss of insulin secretion in the background of insulin _______(2).
  • Patients with type 2 DM are often _______(3), have ______(e) to the effects of insulin (commonly referred to as insulin resistance), and, hence, may have normal or even elevated levels of insulin, initially.
  • In milder forms, this version of diabetes can often be treated with diet, lifestyle modifications, and oral hypoglycemic agents.
  • Because type 2 are relatively _______(4) to ketosis, their disease may not be clinically apparent until exacerbated by the stress of surgery or intercurrent illness.
• Gestational DM
• Diabetes due to other causes.
• For decades, the diagnosis of diabetes was based on plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-hour value in the 75-g oral glucose tolerance test (OGTT). Starting in 2009, the criteria to diagnose DM was amended and now includes hemoglobin A1c (HbA1c) above _______(5).

Answer 38

Answers:
a. 1
b. 1
c. 1
1. insulin
d. adult
2. resistance
3. obese
e. resistance
4. resistant
5. 6.5%

Question 39

Criteria for the Diagnosis of Diabetes

• A1c ≥_______(1)%. The test should be performed in a laboratory using a method that is certified and standardized.
• Fasting plasma glucose ≥_______(2) mg/dL (7 mmol/L). Fasting is defined as no caloric intake for at least 8 h^a.
• 2-h plasma glucose ≥_______(3) mg/dL (11.1 mmol/L) during an oral glucose tolerance test. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
• In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥_______(4) mg/dL (11.1 mmol/L).

^aIn the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.

Adapted from Surks MI, Sievert R. Drugs and thyroid function. N Engl J Med. 1995;333:1688–1694.

Answer 39

Answers:
1. 6.5
2. 126
3. 200
4. 200

Question 40

Anesthetic Management for Diabetic Patients

• Successful management of diabetic patients is as dependent on, or more dependent on, chronic complication management than acute hyperglycemia.
• Preoperative
  
  • Preoperative evaluation and management has three important goals:
    
    • One is determining end-organ complications of DM.
      
      • This requires a thorough history and physical, a recent ECG, blood urea nitrogen, potassium, creatinine, glucose, and _______(1).
    • Second is determining the patient’s glucose-lowering regimen. Patients may be on different types of insulin regimens and oral hypoglycemic agents.
      
      • Preoperative counseling has to be specific to the patient’s glucose-lowering regimen.
    • The third goal is to determine patient glycemic control and the need for preoperative intervention to control glucose levels.
• End Organ Complications of Diabetes
  
  • _______(2) develops earlier and is more widespread in diabetic patients compared with nondiabetics.
    
    • Manifestations include coronary artery disease, peripheral vascular disease, cerebrovascular disease, and renovascular disease.
  • The American College of Cardiology (ACC)/American Heart Association guidelines recognize DM as a risk factor when evaluating patients for noncardiac surgery.
    
    • Preoperative hyperglycemia, as documented by increased HbA1c, has consistently been associated with poor perioperative outcomes in a variety of clinical situations.
  • Diabetic ______(a) occurs in 20% to 40% of patients with diabetes and is the leading cause of (_______(3)).

Answer 40

Answers:
1. urinalysis
2. Atherosclerosis
a. nephropathy
3. end-stage renal disease (ESRD)

Question 41

Determining Glucose-lowering Regimen and Preoperative Counseling
Patients who are on oral antihyperglycemic medications are advised to _______(1) their medications the night before surgery.
No _______(2) medications are administered or advised on the _______(3) of surgery.
Medications are _______(4) after the patient has resumed a _______(5).

For patients who are taking short- or long-acting insulin preparations, adjustment of the insulin should take into account the timing of their insulin regimen (Table 47-12).
Patients who take both evening and morning doses of insulin should _______(6) their usual dose of evening short-acting insulin, but _______(7) their intermediate- or long-acting insulin dose by 20% the night before surgery.
On the morning of surgery, they should _______(8) their morning short acting insulin and _______(9) the intermediate- or long-acting dose by ______(a)% (and take this only if the fasting glucose is > _______(10) mg/dL).

Answer 41

Answers:
1. discontinue
2. oral hypoglycemic
3. morning
4. reinstated
5. normal diet
6. take
7. reduce
8. omit
9. reduce
a. 50
10. 120

Question 42

Preoperative Glycemic Control

Given the multitude of patient factors involved as well as the variety of surgical procedures and procedure urgency, it is unlikely that recommendations based on outcomes will be _______(1).
Providers need to weigh several issues when considering this question.
First, the urgency of surgery should be considered.
Second, hyperglycemia could represent an unstable metabolic state, such as diabetic ketoacidosis (DKA), which should be _______(2) in the preoperative area.
_______(3) surgery in an unstable metabolic state is not recommended.

Another consideration is that the hyperglycemia may be caused by the illness for which the patient presented for surgery (e.g., wound infection, intra-abdominal sepsis, osteomyelitis), which would not be expected to improve until the patient undergoes surgery and source control is achieved.

Intraoperative
Blood glucose levels should be measured before, during, and after surgery.
Blood glucose should be monitored every _______(4) to 6 hours while the patient is NPO.
_______(5) measurements are reasonable in high-risk patients, especially those receiving continuous insulin through either an insulin pump or infusion.

Answer 42

Answers:
1. forthcoming
2. rapidly assessed
3. Elective
4. 4
5. Hourly

Question 43

Figure 47-8 → Relation Among Perioperative Injury, Hyperglycemia, and Outcomes (Reads right off this chart)

Hyperosmolar Nonketotic Coma
An occasional elderly patient with minimal or mild DM may present with remarkably high blood glucose levels (>_______(1) mg/dL) and profound dehydration (_______(2) L).
The marked hyperosmolarity may lead to _______(3), with the increased plasma viscosity producing a tendency to ______(a).
Treatment → If you treat the ______(b) prior to giving ______(c), you will cause cardiovascular collapse.
If there are no cardiovascular contraindications, 1 to 2 L (or _______(4) mL/kg) of normal saline should be infused over _______(5).
Insulin, by bolus or infusion, should be administered _______(6) initial volume has been administered.

Diabetic Ketoacidosis
DKA is defined by the biochemical triad of _______(7), _______(d), and ________(e).
Blood sugar levels are often in the _______(8) -mg/dL range.
The patient is always dehydrated because of the combination of the hyperglycemia-induced osmotic diuresis and the nausea and vomiting typical of this syndrome.
Because leukocytosis, abdominal pain, GI ileus, and mildly elevated amylase levels are all common in ketoacidosis, an occasional patient is misdiagnosed as having an _______(9) surgical problem.
Diagnostic criteria for DKA include _______(10) or significant _______(f); blood glucose above 250 mg/dL or new DM; and serum bicarbonate below _______(11) mmol/L or arterial pH less than _______(12).
Treatment of DKA includes insulin administration and fluid and electrolyte replacement.

Answer 43

Answers:
1. 600
2. 9 to 12
3. coma and seizures
a. intravascular thrombosis
b. sugar
c. volume
4. 15 to 30
5. 1 hour
6. after
7. ketonemia
d. hyperglycemia
e. acidemia
8. 250-to 500
9. intra-abdominal
10. ketonemia
f. ketonuria
11. 18
12. 7.3

Question 44

Hypoglycemia
Clinically significant hypoglycemia is defined by Whipple triad:
(a) Symptoms of _______(1)
(b) simultaneous blood glucose concentration below _______(2) mg/dL
(c) relief of symptoms with _______(3) administration.

Although a subclinical stress response may be initiated at glucose levels below 70 mg/dL, a blood glucose level of approximately _______(4) mg/dL results in activation of the sympathetic nervous system and autonomic symptoms, which include sweating, palpitations, tremor, and hunger.
Neuroglycopenic symptoms occur with blood glucose levels of approximately _______(5) mg/dL, and include behavioral and cognitive impairment, drowsiness, speech difficulty, blurred vision, seizures, coma, and death.
Hypoglycemia in hospitalized patients has been defined as blood glucose below _______(6) mg/dL (3.9 mmol/L) and severe hypoglycemia as less than _______(7) mg/dL (2.2 mmol/L).

Answer 44

Answers:
1. neuroglycopenia
2. 40
3. glucose
4. 55
5. 45
6. 70
7. 40

Question 45

Pituitary Gland
The pituitary gland is located below the base of the brain in a bony structure called the _______(1).
Anterior Pituitary
Hyposecretion of anterior pituitary hormones is usually due to _______(2) of the gland by tumor.
Panhypopituitarism after postpartum hemorrhagic shock (______(a) syndrome) is due to necrosis of the anterior pituitary gland.
Radiation therapy delivered to the _______(3) or nearby structures and surgical hypophysectomy are other causes of panhypopituitarism.
Panhypopituitarism is treated with specific hormone replacement therapy, which should be _______(4) in the perioperative period.
Stress doses of _______(5) are necessary for patients receiving steroid replacement because of inadequate ACTH.

The hypersecretion of various anterior pituitary hormones is usually caused by an _______(6).
Excess _______(7) secretion with galactorrhea is a common hormonal abnormality associated with pituitary adenoma.
Cushing disease may occur secondary to excess _______(8) production, and gigantism or acromegaly may occur as a consequence of excess growth hormone production in the child or adult, respectively.
Excessive secretion of TSH is ________(9).

Answer 45

Answers:
1. sella turcica
2. compression
a. Sheehan
3. sella turcica
4. continued
5. corticosteroids
6. adenoma
7. prolactin
8. ACTH
9. rare

Question 46

Posterior Pituitary
The posterior pituitary, or _______(1), is composed of terminal nerve endings that extend from the _______(a).
______(b) (antidiuretic hormone [ADH]) and _______(2) are the two principal hormones secreted by the posterior pituitary.
Both hormones are synthesized in the _______(3) and ______(c) nuclei of the hypothalamus.
They are bound to inactive carrier proteins, neurophysins, and transported by axons to membrane-bound storage vesicles located in the posterior pituitary.
ADH is a ______(d) that circulates as a free peptide after its release → IS NOT A _______(4)!

The primary functions of ______(e) are maintenance of extracellular fluid volume and regulation of _______(5) osmolality.
_______(6) elicits contraction of the uterus and promotes milk secretion and ejection by the mammary glands.

Answer 46

Answers:
1. neurohypophysis
a. ventral hypothalamus
b. Vasopressin
2. oxytocin
3. supraoptic
c. paraventricular
d. nonapeptide
4. CATECHOLAMINE
e. ADH
5. plasma
6. Oxytocin

Question 47

Diabetes Insipidus

Diabetes insipidus results from inadequate secretion of _______(1) or resistance on the part of the renal tubules to ______(a)(nephrogenic diabetes insipidus).
Failure to secrete adequate amounts of ADH results in _______(2), ______(b), and a high output of poorly concentrated urine.
Hypovolemia and ______(c) may become so severe as to be life-threatening.
This disorder usually occurs after destruction of the pituitary gland by intracranial trauma, infiltrating lesions, or _______(3).
Patients in whom diabetes insipidus develops secondary to severe head trauma or subarachnoid hemorrhage often have impending brain death or are presenting for organ retrieval.
Treatment of diabetes insipidus depends on the extent of the hormonal deficiency.
During surgery, the patient with complete diabetes insipidus can be treated with _______(4) infusion combined with administration of an _______(5) crystalloid solution.
The serum sodium and plasma osmolality are measured on a regular basis and therapeutic changes are made accordingly.

Answer 47

Answers:
1. ADH
a. ADH
2. polydipsia
b. hypernatremia
c. hypernatremia
3. surgery
4. DDAVP or vasopressin
5. isotonic

Question 48

Inappropriate Secretion of Antidiuretic Hormone
Inappropriate and excessive secretion of ADH may occur in association with a number of diverse pathologic processes, including head injuries, intracranial tumors, pulmonary infections, small cell carcinoma of the lung, and _______(1).
The clinical manifestations occur as a result of a dilutional hyponatremia, decreased serum osmolality, and a reduced urine output with a _______(2) osmolar weight gain, skeletal muscle weakness, and mental confusion or convulsions are presenting symptoms.
The treatment for patients with mild or moderate water intoxication is restriction of fluid intake to _______(3) mL/day.
Patients with severe water intoxication associated with hyponatremia (sodium <120 mEq/L) and central nervous system symptoms may require more aggressive therapy, with the IV administration of a _______(4) saline solution.
This may be administered in conjunction with furosemide.
Too-rapid correction of hyponatremia may induce _______(5) and cause permanent brain damage.
Serum sodium should not be raised by more than _______(6) mEq/L in 24 hours.

Answers:
1. hypothyroidism
2. high
3. 800
4. hypertonic
5. osmotic demyelination
6. 9

Question 49

CHAPTER 50 → THE RENAL SYSTEM AND ANESTHESIA FOR UROLOGIC SURGERY @ 58:32

Key Points

1 Renal filtration and reabsorption are susceptible to alterations by surgical illness and anesthesia.
Autoregulation of renal blood flow (RBF) is effective over a wide range of mean arterial pressures (_______(1) to _______(2) mmHg). Autoregulation of urine flow does not occur, but a linear relationship between mean arterial pressure above _______(3) mmHg and urine output is observed.
2 Renal medullary blood flow is low (2% of total RBF) but central to the kidneys’ ability to _______(4) urine. During periods of reduced renal perfusion, the metabolically active medullary thick ascending limb may be especially vulnerable to ischemic _______(5).

Answer 49

Answers:
1. 50
2. 150
3. 50
4. concentrate
5. injury

Question 50

3 The physiologic response to surgical stress invokes intrinsic mechanisms for sodium and water conservation. Renal cortical vasoconstriction causes a shift in perfusion toward _______(1) nephrons, a _______(2) in glomerular filtration rate, and _______(3) of salt and water result.
4 The stress response may induce a decrease in RBF and glomerular filtration rate, causing afferent arteriolar _______(4). If this situation is not reversed, ischemic damage to the kidney may result in acute renal failure (ARF).
5 Anesthetic-induced reductions in RBF have been described for many agents but are usually clinically insignificant and reversible. Likewise, anesthetic agents have not been shown to interfere with the renal response to physiologic stress.
6 Isolated ARF carries a mortality of up to 80% in surgical patients, with _______(5) being the cause of ARF in most of these patients.
7 Surgical patients with non–dialysis-dependent chronic kidney disease are at higher risk of developing end-stage renal disease. The single most reliable predictor of new postoperative need for dialysis is _______(6) renal insufficiency.
8 Overall, there are no conclusive comparative studies demonstrating superior renal protection or improved renal outcome with general versus _______(7).
9 Maintaining adequate intravascular volume and hemodynamic stability with aggressive management of kidney hypoperfusion is a basic principle of anesthetic care to prevent acute kidney injury.
10 Urologic patients are often elderly, have numerous comorbidities, and require critical evaluation prior to any urologic procedure.

Answer 50

Answers:
1. juxtamedullary
2. decrease
3. retention
4. vasoconstriction
5. acute tubular necrosis
6. preoperative
7. regional anesthesia

Question 51

11 Combining _______(1) with general anesthetic techniques for some major urologic surgeries may offer advantages for accelerated recovery, improved analgesia, and even better outcomes, but these techniques must be conducted with respect for other perioperative issues, including thromboprophylaxis for prevention of deep venous thrombosis.
12 Watchful waiting, minimally invasive principles, and technologic innovation (e.g., laparoscopy, robotics) have changed the favored approach to many kidney, bladder, and prostate disorders, in some cases reducing the number of high-risk surgeries, in others creating other safer and less morbid alternate treatments.
13 Absorption of irrigating solution related most often to transurethral prostate or bladder tumor resections can cause “_______(2) syndrome,” a condition that while becoming less common has the potential to be serious and even life-threatening during the several hours following surgery. Knowledge of specific concerns relevant to the different irrigating solutions, vigilance of the anesthesiologist to factors that minimize absorption, recognition of signs and symptoms, and appropriate treatment, are key to favorable outcomes with this condition.

Answer 51

Answers:
1. epidural
2. TUR

Question 52

Renal Anatomy and Physiology
The kidneys lie in the paravertebral gutters, behind the peritoneum, with the right kidney resting slightly _______(1) than the left one owing to the presence of the liver.
During its ascent, the kidney receives blood supply from several successive sources, such that an accessory renal artery from the aorta may be found entering the lower pole of the kidney.
When first formed, the rudimentary kidneys are close together and may fuse to give rise to a _______(2) kidney.
This organ is unable to ascend, “held in place” by the _______(3) artery, and thus when present it remains forever a pelvic organ.
The bladder is located in the retropubic space and receives its innervation from sympathetic nerves originating from _______(4), which conduct pain, touch, and temperature sensations, whereas bladder stretch sensation is transmitted via parasympathetic fibers from segments _______(5) to S4.
Parasympathetics also provide the bladder with most of its _______(6) innervation.

The renal artery enters the kidney at the _______(7).

Answer 52

Answers:
1. lower
2. horseshoe
3. inferior mesenteric
4. T11 to L2
5. S2
6. motor
7. hilum

Question 53

Correlation of Structure and Function
Because renal tissue makes up only 0.4% of body weight but receives ______(a)% of cardiac output, the kidneys are by far the most highly perfused major organs in the body, and this facilitates plasma filtration at rates as high as _______(1) mL/min in young adults.
The functions of the kidney are many and varied, including waste filtration, endocrine and exocrine activities, immune and metabolic functions, and maintenance of physiologic homeostasis.
As well as tight regulation of extracellular solutes such as sodium, potassium, hydrogen, bicarbonate, and glucose, the kidney also generates ammonia and glucose and eliminates nitrogenous and other metabolic wastes including urea, creatinine, bilirubin, and other uremic toxins (i.e., substances that have toxic effects when they accumulate due to renal impairment).

Glomerular Filtration
Production of urine begins with water and solute filtration from plasma flowing into the glomerulus via the _______(2) arteriole.
The glomerular filtration rate (GFR) is a measure of glomerular function expressed as milliliters of plasma filtered per minute.
The two major determinants of filtration pressure are:
- Glomerular _______(3) pressure (PGC)
- Glomerular _______(4) pressure (pgc).
PGC is directly related to renal artery pressure and is heavily influenced by arteriolar tone at points upstream (_______(5)) and downstream (_______(6)) from the glomerulus.

Answer 53

Answers:
a. 25
1. 125 to 140
2. afferent
3. capillary
4. oncotic
5. afferent
6. efferent

Question 54

Autoregulation of Renal Blood Flow and Glomerular Filtration Rate
Renal blood flow (RBF) autoregulation maintains relatively constant rates of RBF and glomerular filtration over a wide range of arterial blood pressure.
Renal autoregulation of blood flow and filtration is accomplished primarily by local feedback signals that modulate glomerular arteriolar tone to protect the glomeruli from excessive perfusion pressure.

Tubular Reabsorption of Sodium and Water
The proximal tubule reabsorbs _______(1) of the filtered sodium.
Here, an adenosine triphosphatase pump (ATP) drives the sodium into tubular cells while _______(2) ions passively follow.
Reabsorption of water is a _______(3), _______(4) driven process tied to the reabsorption of sodium and other solutes.

Answer 54

Answers:
1. two-thirds
2. chloride
3. passive
4. osmotically

Question 55

Renal Function Tests
_______(1) urine is due to suspended elements such as white or red blood cells and/or crystals.
Urine protein electrophoresis can differentiate proteinuria from a glomerular (filtering), tubular (reuptake), overflow (supply that saturates the reuptake system), or tissue (e.g., kidney inflammation) abnormality.
In contrast, color changes reflect dissolved substances; this occurs most commonly with _______(2), but other causes include food colorings, drugs, and liver disease (e.g., bilirubin).
Unusual odors are less common but can also be diagnostic (e.g., maple syrup urine disease).
Urine specific gravity (the weight of urine relative to distilled water) normally ranges between 1.001 and _______(3) and can be used as a surrogate for osmolarity (normal 50 to 1,000 mOsm/kg), with _______(4) reflecting a specific gravity similar to that of plasma.

High specific gravity (>_______(5)) implies preserved renal concentrating ability, unless high levels of glucose, protein, or contrast dye injection have raised specific gravity without significantly changing osmolarity.
Although poor urine output (e.g., <_______(6) mL urine/24 hr) may reflect hypovolemia or impending prerenal renal failure, a majority of perioperative AKI episodes develop in the absence of oliguria.
possible t/f question?

Answer 55

Answers:
1. Cloudy
2. dehydration
3. 1.035
4. 1.010
5. 1.018
6. 400

Question 56

Hyponatremia
Hyponatremia is the most commonly occurring electrolyte disorder.
Symptoms rarely occur unless sodium values are less than _______(1) mmol/L, and these include a spectrum ranging from anorexia, nausea, and lethargy to convulsions, dysrhythmias, coma, and even death due to osmotic brain swelling.
Hyponatremia may occur in the setting of an _______(2) (e.g., transurethral resection [TUR] syndrome), normal, or contracted extracellular fluid volume.

Hypernatremia
Hypernatremia (serum sodium >_______(3) mmol/L) is generally the result of sodium gain or _______(4) loss, most commonly the latter.
Dehydration of brain tissue can cause symptoms ranging from confusion to convulsions and coma.
In cases of hypernatremia, laboratory studies often show evidence of _______(5) (increased hematocrit and serum protein concentrations).
The primary goal of treatment is restoration of serum tonicity, which can be achieved with _______(6) or _______(7) parenteral fluids and/or diuretics unless irreversible renal injury is present, in which situation dialysis may be necessary.

Answer 56

Answers:
1. 125
2. expanded
3. 145
4. water
5. hemoconcentration
6. isotonic
7. hypotonic

Question 57

Hypokalemia

Hypokalemia may be due to a net potassium deficiency or transfer of extracellular potassium to the intracellular space.
Notably, total body depletion may exist even with normal extracellular potassium levels (e.g., diabetic ketoacidosis).
Causes of hypokalemia include extrarenal loss (e.g., _______(1), _______(2)), renal loss (impaired processing due to drugs, hormones, or inherited renal abnormalities), potassium shifts between the extra- and intracellular spaces (e.g., _______(3) therapy), and, occasionally, inadequate intake.
Clinical manifestations of hypokalemia include electrocardiography (ECG) changes (______(a) T waves—“no pot, no T,” _______(4) waves, prodsyrhythmic state) and skeletal muscle _______(5).

Hyperkalemia

If a patient has hyperkalemia (elevated serum potassium level >_______(6) mEq/L), it is important to consider the duration of the condition because chronic hyperkalemia is far better tolerated than an acute rise.
Other than laboratory artifacts (e.g., _______(7) sample), causes of hyperkalemia include abnormal kidney excretion, abnormal cellular potassium release, or abnormal distribution between the intracellular and the extracellular space.
Clinical manifestations of acute hyperkalemia include a range of ECG changes that can be clearly observed with the infusion of high-potassium cardioplegia immediately following aortic _______(8) application during cardiac surgery.
_______(9) T waves, ST segment _______(10), and ______(b) QT interval are soon followed by manifestations of severe hyperkalemia, including QRS complex ______(c), _______(11) PR interval, disappearance of the P wave, sine wave QRS, ventricular fibrillation, and asystole.

Answer 57

Answers:
1. vomiting
2. diarrhea
3. insulin
a. flattened
4. U
5. weakness
6. 5.5
7. hemolyzed
8. cross-clamp
9. Peaked
b. shortened
10. depression
c. widening
11. prolonged

Question 58

Disorders of Calcium, Magnesium, and Phosphorus (Said read about it)
Most of a grown adult’s 1 to 2 kg of calcium is in bone (98%), with the remaining 2% in one of the three forms: ionized, chelated, or protein bound.
Normal serum calcium values range between _______(1) and _______(2) mg/dL, but only the ionized fraction (50%) is biologically active and precisely regulated.
Ionized extracellular calcium concentration (iCa++) is controlled by the combined actions of ______(3) and further modulated by dietary and environmental factors.
The clinical manifestations of hypocalcemia include cramping, digital numbness, laryngospasm, carpopedal spasm, bronchospasm, seizures, and respiratory arrest.
A positive ______(a) sign (facial muscle twitching in response to tapping the facial nerve) or Trousseau sign (carpal spasm induced by brachial artery occlusion) are the classic hallmarks of hypocalcemia but in practice are often absent.
Mental status changes, including irritability, depression, and impaired cognition may also occur.
Cardiac manifestations include QT interval _______(5) and dysrhythmias.
Hypocalcemia may be due to several mechanisms, including a decrease in PTH secretion or action, reduced vitamin D synthesis or action, resistance of bone to PTH or vitamin D effects, or calcium sequestration.
Acute hypocalcemia due to citrate toxicity can develop from rapid infusion of citrate-stored packed red blood cells, particularly with citrate accumulation during the anhepatic phase of liver transplant procedures.

Answer 58

Answers:
1. 8.5
2. 10.2
3. parathyroid hormone (PTH), calcitonin, and vitamin D
a. Chvostek
4. calcitonin
5. prolongation

Question 59

Clinical symptoms of hypercalcemia correlate with its acuity and include constipation, nausea and vomiting, drowsiness, lethargy, weakness, stupor, and coma.
Cardiovascular manifestations may include hypertension, _______(1) QT interval, heart block, and other dysrhythmias.
The most frequent causes of hypercalcemia are primary _______(2) and malignancy.

Magnesium is a multifunctional _______(3) that is found primarily in the intracellular space.
Because extracellular magnesium represents only 0.3% of total (mainly intracellular) stores, normal serum levels (1.6 to 2.2 mg/dL) are a poor reflection of total body magnesium.
Hypomagnesemia (<1.6 mg/dL) may sometimes be asymptomatic, but clinically important problems can and do manifest, including neuromuscular, cardiac, neurologic, and related electrolytic ( _______(4)) abnormalities.
Causes of hypomagnesemia can be divided into four broad categories: decreased intake, gastrointestinal loss, renal loss, and redistribution.
Nutritional hypomagnesemia can result from malabsorption syndromes in patients receiving parenteral nutrition, and it is also present in 25% of _______(5).
Redistribution occurs with acute _______(6), administration of catecholamines, and “______(a) syndrome” after parathyroidectomy.
Magnesium can be supplemented orally or via the parenteral route.

Answer 59

Answers:
1. shortened
2. hyperparathyroidism
3. cation
4. hypokalemia and hypocalcemia
5. alcoholics
6. pancreatitis
a. hungry bone

Question 60

Clinical manifestations of hypermagnesemia (>4 to 6 mg/dL) are serious and potentially fatal. Minor symptoms include hypotension, nausea, vomiting, facial flushing, urinary retention, and ileus.
In more extreme cases, flaccid skeletal muscular paralysis, hyporeflexia, bradycardia, bradydysrhythmias, respiratory depression, coma, and cardiac arrest may occur.
Hypermagnesemia generally occurs in two clinical settings: compromised renal function (GFR < _______(1) mL/min) and excessive magnesium intake (e.g., excessive intravenous therapy in preeclampsia).

Phosphorus is a major intracellular _______(2) that plays a role in regulation of glycolysis, ammoniagenesis, and calcium homeostasis and is an essential component of adenosine triphosphate and red blood cell 2,3-_________(3) acid synthesis.
Hypophosphatemia is clinically ______(a) important than hyperphosphatemia and can result in symptoms including muscle weakness, respiratory failure, and difficulty in weaning critically ill patients from _______(4) when serum levels are less than 0.32 mmol/L.
In addition, low phosphate levels may diminish oxygen delivery to tissues and rarely cause hemolysis.
Hypophosphatemia can result from intracellular redistribution (from catecholamine therapy), from inadequate intake or absorption secondary to alcoholism or malnutrition, or from increased renal or gastrointestinal losses.
same as hypomagnesemia!
Hyperphosphatemia (>5 mg/dL) is generally related to accompanying _______(5) although increased phosphate levels may also lead to calcium precipitation and decreased intestinal calcium absorption.
Significantly elevated serum phosphate levels are most commonly due to reduced excretion from renal insufficiency but can also result from excess intake or redistribution of intracellular phosphorus.

Answer 60

Answers:
1. 20
2. anion
3. diphosphoglyceric
a. more
4. mechanical ventilation
5. hypocalcemia

Question 61

Acute Kidney Injury
AKI is now the preferred term for an acute deterioration in renal function. It is associated with a decline in glomerular filtration and results in inability of the kidneys to excrete nitrogenous and other wastes.
This manifests as an accumulation of _______(1) and _______(2) in the blood (uremia) and is often accompanied by reduced urine production, although nonoliguric forms of postoperative AKI are common.
In surgical patients, _______(3) is the most common cause of AKI. AKI frequently occurs in the setting of critical illness with multiple organ failure when the mortality is alarmingly high (up to 80%)

Prerenal Azotemia
Prerenal azotemia is the increase in _______(4) associated with renal hypoperfusion or ischemia that has not yet caused renal parenchymal damage.
BUN: Cr ratio of _______(5)

Intrinsic Acute Kidney Injury
The term intrinsic not only implies a primary renal cause of AKI but also includes AKI due to ischemia, nephrotoxins, and renal parenchymal diseases.
_______(6) remains the most common ischemic lesion and represents an extension of prerenal azotemia, whereas cortical necrosis may follow a massive renovascular insult such as prolonged suprarenal aortic clamping or renal artery embolism.

Postrenal Acute Kidney Injury (Obstructive Uropathy)
Downstream obstruction of urinary collecting system = least common pathway to est’d AKI, accounting for <10% of cases. B/c it can generally be corrected, it is extremely important to exclude w/ renal US exam as source of AKI.

Table 50.1 NEPHROTOXIN
STUDY

Answer 61

Answers:
1. creatinine
2. urea
3. ATN (Acute Tubular Necrosis)
4. BUN (Blood Urea Nitrogen)
5. 20:1
6. ATN (Acute Tubular Necrosis)

Question 62

Nephrotoxins & Periop AKI
Nephrotoxins may take form of drugs, non-toxic chemicals, heavy metals, poisons, & endogenous compounds
nephrotoxins most likely→ renal dysfx/failure in periop period are certain antimicrobial & chemotherapeutic–immunosuppressive agents, ______(a) media, ______(b), & endogenous heme pigments: myoglobin & _______(1).

CKD
Pts w/ non–dialysis-dependent CKD = ______(c) risk of developing ESRD.
ESRD: clinical syndrome c/b renal dysfx that would prove fatal w/o renal replacement therapy (i.e., dialysis)
Uremic syndrome represents extreme form of CRF, which occurs as surviving nephron population & GFR ↓ below 10% of normal
→ failure both to conserve water & excrete H2O. Pts w/ uremic syndrome often require frequent/continuous ______(d).
LT hyperkalemia may occur d/t slower-than- normal K+ clearance
CV comps = d/t volume overload, ______(e) renin–angiotensin activity, ANS hyperactivity, ______(f), & electrolyte disturbances
______(g) d/t ECF volume expansion, autonomic factors, & _______(2) is almost universal finding in ESRD
Together w/ volume overload, acidemia, anemia, & possibly presence of high-flow arteriovenous fistulae created for dialysis access, HTN may contribute to development of myocardial dysfx & HF
______(h) may occur 2º to uremia/HD w/ pericardial tamponade developing in 20% of latter group

Answer 62

Answers:
a. radiocontrast
b. NSAIDs
1. hgb (hemoglobin)
c. increase
d. dialysis
e. high
f. acidosis
g. HTN
2. hyperreninemia
h. Pericarditis

Question 63

Anesthetic agents for RF
Drugs eliminated unchanged by kidneys (i.e. certain _______(1), cholinesterase inhibitors, many abx, digoxin) have prolonged elim. ½-life when given to pts w/ RF.
Many drugs used in anesthesia = highly protein bound & can show exaggerated clinical effects when protein binding = inc by uremia
______(a) (75% PB normal pts), has larger free fraction in pts w/ ESRD but Δ’d PB does not seem to alter clinical FX of etomidate ANE induction in pts w/ RF

Benzos = _______(2) PB
CKD increases free fraction of benzos in plasma & potentiates their clinical FX
Certain benzos metabolites = pharmacologically active & have potential to accumulate w/ repeated admin of parent drug to anephric pt

Dexmedetomidine = primarily biotx’d in liver
Experience ______(b)-lasting sedative effects
Less protein binding of dexmedetomidine occurs in subjects w/ renal _______(3)

Answer 63

Answers:
1. NDMRs (Non-Depolarizing Muscle Relaxants)
a. Etomidate
2. extensively
b. longer
3. dysfx (dysfunction)

Question 64

Anesthetic agents for RF

Hydromorphone is biotx’d to ______(a), excreted by kidneys
- active metabolite accumulates in RF pts → cognitive _______(1) & myoclonus
- ______(b)→ prolonged narcosis & cannot be recommended for LT use
Morphine → Chronic admin → accumulation of its 6-glucuronide metabolite, which has potent analgesic & sedative effects.
- dec PB of morphine in ESRD = dec initial dose.
Fentanyl = better choice of opioid for ESRD b/c of its lack of active metabolites, unchanged free fraction, & short redistribution phase
- Small-to-mod doses, titrated to effect, are well tolerated by uremic pts
Alfentanil = reduced PB but no change in elim. ½-life/ clearance in ESRD & ↑↑biotx’d to inactive compounds
- → prolonged narcosis
Remifentanil = rapidly biotx’d by blood & tissue esterases to weakly active (4,600X <potent) m-opioid agonist & renally excreted metabolite
Only ______(c) = minimal renal excretion of unchanged parent compound
Intermediate-acting MR’s (atracurium, cis-atracurium, vecuronium, & rocuronium) = distinct ______(d) in ESRD d/t shorter duration
Atracurium, cis-atracurium - enzymatic ester hydrolysis & spont. nonenzymatic (Hoffman) degradation w/ minimal renal excretion of parent compound
- elim ½-life/clearance/DOA = not affected by RF
Vecuronium’s DOA = prolonged d/t decreased plasma clearance & increased elim ½-life. An intubating dose lasts ≈50% longer in ESRD
- active metabolite, 3- _______(2), ocnt.vecuronium gtt→ prolonged blockade
Roc = OK
Mivacurium (short-acting MR) = enzymatically eliminated by plasma pseudocholinesterase at slower < Sch
- maintenance infusion dose = 1.5x normal
Sch → hyperK+

Table 50.3 Uremic Syndrome
STUDY

Table 50.2 Factors contributing to K+ in ESRD - STUDY

Answer 64

Answers:
a. hydromorphone-3- glucuronide
1. dysfx (dysfunction)
b. Codeine
c. Sch, atracurium, cis-atracurium, & mivacurium
d. advantage
2. desmethylvecuronium

Question 65

Diuretics Effects & Mechanisms
Diuretics = grouped according to site & MOA
- may develop metabolic _______(1) when taking these agents, compensatory processes in tubules accommodate effects of carbonic anhydrase inhibitors so that their LT-use rarely causes this problem
Substances i.e. mannitol = freely filtered at glomerulus but poorly reabsorbed by renal tubule → osmotic _______(2)
- ______(a) - used as strategy to prevent AKI but can decrease _______(3)

Electrochemical gradient est’d by Na+/K+-ATPase in loop of Henle drives tx of 1 Na+, 1 K+, & 2 Cl− ions into tubule cells from tubular fluid
- d/t thick ascending limb segment of loop of Henle = H2O impermeable, reabsorption of solute cx’s interstitium & dilutes tubular fluid
______(b) diuretics (i.e.furosemide, bumetanide, & torsemide)
- directly inhibit electroneutral tx/r, preventing salt reabsorption
- d/t 25% of filtered NaCl = normally reabsorbed in loop of Henle, loop diuretics → large salt load to pass to distal convoluted tubule that is beyond extra reserve of this tubular segment to reabsorb → large volumes of dilute urine ensure

Answer 65

Answers:
1. acidosis
2. diuresis
a. Mannitol
3. ICP (Intracranial Pressure)
b. Loop

Question 66

High Risk Surgical Procedures
Cardiac Surgery
- Cardiac operations requiring CPB (no _______(1) flow) can be expected → AKI/RF in ≤ 7% of patients
- RF’s w/ development of postoperative AKI in this population
- Renal ischemia-reperfusion, inflammatory mediators, and toxin exposure are considered to be primary pathologic mechanisms involved in AKI/ Renal RF’s:
o preoperative left ventricular _______(2)
o duration of CPB
o pulse pressure HTN
o aprotinin

• “_______(a)” off-pump coronary artery bypass grafting decrease renal risk
• ______(b) use during CPB - aimed at avoiding hemoglobin-induced AKI by promoting urine flow & decrease renal cell swelling
• Dopamine to maintain (controversial?)

Answer 66

Answers:
1. pulsatile
2. dysfunction
a. beating heart
b. Mannitol

Question 67

Noncardiac Surgery
- ATN = typical renal lesion a/w trauma & it may be d/t # of ischemic mechanisms
- Preventing AKI in emergency surgery begins w/ proper mgmt of intravascular volume depletion & shock
- Restoring euvolemia while maintaining CO & systemic O2 delivery = important goal
o Urine flow maintained ≥0.5 mL/kg/hr
- Vascular surgery w/ aortic clamping has deleterious FX on renal fx regardless of level of clamp placement
o ______(a) clamping results in an attenuated ATN-like lesion
o ______(b) clamping → smaller, short-lived decrease GFR a/w lower risk of AKI
o thoracic aorta = 25% incidence of AKI
o 2 major predictors of AKI following aortic surgery = pre-existing renal _______(1) & _______(2) HD instability

Nephrectomy
- Approach & incision for nephrectomy = b/o surgical priorities & surgeon preference
- Retroperitoneal approaches require flank incision in lateral decubitus w/ flank extension → kidney access w/o entering peritoneal cavity
o obvious advantages in tx but also simplifies procedures in those with prior abdominal surgery or obesity.
Difficulties include:
▪ access to ______(c)
▪ risk of unintentional _______(3)
▪ adverse effects of lateral decubitus position & flank extension on respiratory VC which decrease _____(d)%
- Anterior = supine positioning & breach of peritoneal cavity through midline/subcostal/thoraco abdo. incisions give direct access to both kidney & major vascular structures
o risk of visceral injury and _______(4) (says transperitoneal)
o improve access to renal _______(5) (e.g., trauma, hemorrhage) with best access to both kidneys being thru ______(e)
- Indications (e.g. bilateral nephrectomy for end-stage PCKD).
laparoscopic retro- & transperitoneal approaches to nephrectomy = surpassed open equivalents, esp.simple & donor procedures
10-40% pts with renal CA have associated paraneoplastic syndromes
preop for nephrectomy include:
o routine ECG
o chest x-ray
o complete blood cell count
o electrolyte profile w/ serum BUN/Cr
o liver function tests
o serum calcium assessment
o coagulation testing
o urine analysis

Answer 67

Answers:
a. Suprarenal
b. Infrarenal
1. dysfx (dysfunction)
2. periop (perioperative)
c. vena cava
3. PneumoTX (Pneumothorax)
d. 20
4. peritonitis
5. pedicle
e. midline

Question 68

IntraOP
- most notably significant HRG, an uncommon risk but possible
- Beyond standard monitoring (ASA guidelines), 2 large-bore IV’s & additional monitoring = dictated by patient condition and complexity of procedure and may include peripheral A-line for continuous BP recording & repeated blood gas assessment & CVP
o If CVP - ipsilateral (same side) side to nephrectomy sx for subclavian/IJ central venous puncture to minimize risk of bilateral ______(a)
o If _______(1) → right sided central line
- 80% of pts w/ ______(b) in renal artery dz improves after nephrectomy
- Bladder catheter = essential for all nephrectomy procedures
o UO monitoring provides information on intravascular volume status in the absence of central venous pressure monitoring, avoids the possibility of urinary retention, and also provides valuable information postoperatively regarding renal function, bleeding sources, and the possibility of clot-related urinary tract obstruction.
- <20% pts develop postop complications, operative mortality rates post radical nephrectomy = ≤2%.
Added concerns
o Hemorrhage
o unrecognized visceral injury
o Atelectasis
o Ileus
o superficial & deep wound infx,
o temporary/permanent renal failure
o incisional hernia
- most common radical nephrectomy complications = ______(c) (4% bowel, spleen, liver, diaphragm, or pancreas) & vascular injury

Answer 68

Answers:
a. pneumothorax
1. right sided nephrectomy
b. HTN
c. adjacent organ

Question 69

During donor procedures, several steps are added to simple nephrectomy, including
- admin of IV drugs just prior to explant to achieve low-level AC (i.e., 3,000-USP heparin units)
o forced diuresis (e.g., _______(1); furosemide-______(a)mg)
o extension of (laparoscopic) incisions to ensure atraumatic organ extraction
o postharvest ______(b)

Radical Nephrectomy
- ______(c) carcinoma = main indication for radical nephrectomy (90-95% of kidney neoplasm)
- _______(2), a palpable _______(3), & flank pain compose classic triad
o renal tumors are more often ( ≈ 7%) diagnosed incidentally during workup for other nonurologic problems
o Tumors = found owing to s/sx of vena cava involvement i.e. dilated abdominal veins, (L) varicocele, LE edema, or PE
- Sx tumors usually reflect more advanced dx & more often a/w metastasis & poor prognosis
- Radical nephrectomy involves:
o renal artery & vein ligation
o w/ subsequent removal en bloc of kidney
o perinephric fat
o Gerota fascia
o proximal ureter
o adjacent adrenal gland
- Lymph node dissection = then performed from diaphragm to aortic bifurcation

Most renal Ca’s stay w/in Gerota fascia & completely removed, but disappointing 20-30% pts w/ successful surgery still have disease return

Answer 69

Answers:
1. mannitol-12.5 g
a. 40
b. protamine
c. Renal cell
2. Hematuria
3. mass

Question 70

Radical Nephrectomy w/ IVC Tumor Thrombus
- B/w 4-10% w/ renal cell carcinoma have so-called tumor thrombus extension beyond kidney, either w/in renal vein/extending into IVC
- Challenging owing to risk of sudden major bleeding & potential for acute HD instability (i.e. IVC clamping/tumor PE)
- W/ Sternotomy incision → procedures require standard heparin AC & employ added circuit venous line filter to trap tumor fragments
- Appropriate considerations include A-line, CVP/PCP & intraopTEE
- Cell saver technology use is discouraged owing to potential for returning tumor _______(1) circulation

Nephron-Sparing Partial nephrectomy
- Minimizing unnecessary loss of healthy tissue
- Partial nephrectomy = often sufficient for ______(a) tumors
o also becoming alternative to radical nephrectomy for some cancerous renal cell tumors esp.when renal parenchyma must be preserved i.e. bilateral tumors, CKD, tumors in single remaining kidney, or when contralateral kidney = at risk for future disease/tumor
o Even when contralateral kidney is normal, studies are now demonstrating comparable long-term results with nephron-sparing partial nephrectomy procedures as with radical nephrectomy for patients with a single, localized small tumor (<4 cm) or even medium- sized (<7 cm) peripherally located tumors.

Laparoscopic & Robotic Nephrectomies
- Laparoscopic & robotic techniques can be applied to retroperitoneal and transperitoneal approaches and all types of nephrectomies (i.e., radical, simple, or partial). Compared to open approaches, these minimally invasive strategies employ access through small airtight ports.
- Laparoscopic radical nephrectomy for CA involves
o smaller incisions
o dec. blood loss
o dec. postop analgesic requirement
- No NSAIDS d/t _______(2)

Physiology of Pneumoperitoneum
- inc. SVR (afterload) = accompanied by little change/even (16%) in MAP
- SVR & CO usually return to near-normal values over ______(b) mins following institution of pneumoperitoneum

Table 50.5 Physiology of CO2 Pneumoperitoneum In T-burg Position
STUDY

Answer 70

Answers:
1. T cells
a. benign
2. nephrotoxicity
b. 10

Question 71

Cystectomies & other Uro Procedures
- Removal of all/part of urinary bladder
o ______(a) cystectomy = standard for most muscle-invasive malignant disease
o ______(b) cystectomy is primarily for benign bladder disease
- Radical cystectomy combines bladder removal w/ resection of other pelvic organs & lymph nodes.
D/t removal of entire bladder, both procedures require companion surgery to allow for future urine collection
o so-called diversion procedures involve redirecting ureters, most commonly to pouch fashioned from ileum (ileal conduit) that passively drains urine into bag through stoma on pt’s abd wall. Alternate options include the so-called continent diversion reconstructive procedures, which are becoming more popular.
B/c diversion surgeries can make future _______(1) dx difficult, some surgeons also perform appendectomy as part of urinary diversion

Periop Considerations
- Bladder tumors occasionally present w/ urinary retention but dx’d by hematuria (microscopic/macroscopic) w/w/o voiding sx i.e. urgency, frequency, & dysuria
- ______(c) hx = most important, ______(d) risk of bladder Ca, & occ. exposures - leather, dye, rubber & drinking H2O w/ ↑↑ arsenic
o Men = 4x more likely > women
o ______(e) men 2X susceptibility as AA men
o Average age = 65 years old
- ANE mgmt for cystectomy = similar to nephrectomy surgery
o preparation for major bleeding risk
o assessment of IV volume given risk of bleeding & hypovolemia & absence of meaningful UO
- Admission to ICU
- EBL ______(f) mL – transfusion = common

Answer 71

Answers:
a. radical
b. simple
1. appendicitis
c. Smoking
d. doubling
e. white
f. 560-3,000

Question 72

Partial Cystectomy
- Nonmalignant indications for partial bladder resection include bladder endometriosis & benign tumors (e.g., lymphangioma).
- Partial cystectomy FX of added surgery & poorer quality of life a/w urinary diversion procedure = eliminated

Simple & Radical Cystectomy
- Males - bladder = en bloc w/ pelvic peritoneum, prostate & seminal vesicles, ureteric remnants, & small piece of membranous urethra
- Females - uterus, ovaries, fallopian tubes, vaginal vault, & urethra

Prostatectomy
- Almost all procedures involving complete resection of prostate (i.e., prostatectomy) = adenocarcinoma of prostate d/t nonmalignant surgical dx of prostate = typically so amenable to TUR
- Prostate Ca = 2nd most common Ca in most countries, w/ incidence increasing significantly w/ age 50 more common in AA men > white

Preop
- Beyond advanced age, relatively few factors predict likelihood of contracting prostate Ca
- Family hx = ≥2X chances of dz while AA descent inc. risk by 50%

Intraop
- ANE mgmt - open prostatectomy = similar to cystectomy including attentiveness to potential for ______(a)
- Exaggerated lithotomy position a/w ↑↑ rates of neurologic injury (21% w/ transient sensory/motor deficit)
- pts = at greater risk when surgery >_______(1) mins. In addition, even with general anesthesia

Some pts tolerate exaggerated lithotomy–head-down position for perineal prostatectomy poorly d/t ventilation pressures & impaired oxygenation

Answer 72

Answers:
a. major bleeding
1. 180

Question 73

Postop
- most not admitted to ICU
- Average EBL: 500-1500 mL - ~10% pts need _______(1) blood tx
- Transversus abdominis plane blocks = used pain mgmt to facilitate retropubic prostatectomy fast-track recovery protocols
o Otherwise QL to cover the viscera

Laparoscopic Prostatectomy
- c/d less pain, shorter hospital stays, faster recovery, & improved patient satisfaction
- Steep _______(2)

Transurethral Surveillance & Resection Procedures
- TURP = mainstay & gold standard tx to alleviate ______(a) symptoms r/t BPH.
- BPH: smooth muscle & epithelial cell proliferation within the ______(b) zone of the prostate that histologically characterizes this disorder
- Positioning concerns = ______(c) position & r/t adequate padding of pressure points & avoidance of _______(3) nerve compression
- Pts on AC Tx may not be candidates for spinals, d/o indication for anticoagulation
o risk of stopping AC _______(4) may/may not be worth advantages of spinal
- Hypothermia = complication
o Body temperature reduces ______(d)°C/hr of surgery, & shivering (16% pts) who receive room-temp irrigation fluids (very cold)
o Hypothermia does not develop if irrigation solns are warmed to body temp
- EBL 2- 4 mL/min
- Surgical perforation of prostatic capsule occurs in 2% of TURP procedures, usually resulting in extraperitoneal fluid extravasation
o Awake pts w/ neuraxial ANE may complain in surgery of new-onset pain localized to ______(e)
o Bladder perforation → extravasation of fluid intraperitoneally → abd distension & complaints of abd & shoulder pain in awake pts.

• TUR syndrome = common cluster of sx r/t hypervolemic H2O intoxication - principal components:
  1. excessive volume ______(f) (respiratory distress, CHF, pulm. edema, HTN,HR, hypotension)
  2. ______(g) (mental confusion, nausea)
  3. other problems specific to each irrigating solns.

Table 50-6 Irrigating Solutions for TURPs
Table 50-7 Signs and Symptoms of Acute Hyponatremia
Table 50-8 Treatment of the Transurethral Resection Syndrome
STUDY

Answer 73

Answers:
1. eirap
2. Trendelenburg
a. urine obstructive
b. transition
c. lithotomy
3. peroneal
4. periop (perioperative)
d. 1
e. lower and & back
f. expansion
g. hyponatremia

Question 74

Therapies for Urolithiasis
- Pts w/kidney stones typically present w/ intermittent/continuous mod-severe colicky pain in _______(1) flank & upper abd.
o Testicular/labial pain = more typical w/ ______(a) ureteric stones
o Occasionally painless urinary infx/hematuria
- Ca++ salt stone dz = usually ______(b) decades of life & commonly a/w comorbidities i.e obesity, HTN & hyperparathyroidism
- Perc Nephrolithomy -
o GETA allows for secure airway for positioning into ______(c) position & is most commonly used
o spinal anesthesia can also be used
o prone w/ sedation & CT guidance for stent placement

Table 50-10 Contraindications to Shock Wave Lithotripsy
STUDY

Shockwave Lithotripsy
- Dysrhythmias = special problem d/t transmission of ultrasonic pulse = timed & triggered by ECG
- Significant resp & HD changes = a/w immersion & emergence from H2O bath - problematic for pts w/ _______(d) disease.

Ureteroscopy for Removal of Stones
- Performed using urethral LA w/ IV sedation & MAC, spinal, or GA

Answer 74

Answers:
1. ipsilateral
a. distal
b. 3rd-5th
c. prone
d. cardiopulmonary

Question 75

Urological & Pregnancy-related Uro procedures
- Renal colic = #1 most common non OB cause abd pain requiring hospitalization in pregnant women
- Medical mgmt must consider fetal GA in decisions about _______(1) analgesics (i.e. NSAIDs in 3T → premature PDA closure & renal FX
- Interventions in pregnant pts w/ sx nephrolithiasis = limited to ureteral stents to relieve pain & prevent obstruction, w/ definitive therapy delayed post.partum
o need for repeated stent exchanges = common

Impotence Surgery & Medication
- Impotence drugs sildenafil (Viagra), tadalafil (Cialis), & vardenafil (Levitra) all inhibit _______(2) in vascular smooth muscle
o Blocking PDE5 impairs cyclic GMP b/d, mediator of NO FX that → erectile responses to sexual stimulation through penile arterial VD & corpus cavernosum smooth M relaxation
- Rational _______(3) mgmt of PDE5 inhibitor agents = important
o impotence tx = dc’d before surgery to inc risk of ______(a)
o _______(4) HTN tx must continue throughout _______(5) period, take meds the morning of!
whenever these agents are combined w/ systemic NO donors
i.e NTG/Na+ nitroprusside = exaggerated hypotensive responses = d/t dramatic S peripheral vasodilator FX of NO

Answer 75

Answers:
1. appropriate
2. cyclic GMP–specific phosphodiesterase type 5 (PDE5)
3. periop
a. hypotension
4. pulm
5. periop

Question 76

Urological Surgical Emergencies
Testicular Torsion
- Testicular torsion affects 1:_____(1) young men & _____(2)% cases occur in teenagers
- spermatic cord _______(3) - venous outflow from testicle = obstructed & eventually this compromises arterial flow → ischemia & infarction
- present w/ acute scrotal pain & _______(4)
- most cases not involving hx of _______(5)
- predisposing anatomic _______(6) deformity – allows testes to rotate freely in tunica vaginalis = most common cause
- ball clapper more _______(7)!
- Other risk factors include testicular tumors, cryptorchidism hx, & increased testicular volume (e.g., _______(8))
- ANE must respect its emergent nature, including likelihood that pt has not _______(9)
- RA/GA = appropriate, but _______(10) = relatively contraindicated d/t ↑↑ risk postdural puncture HA in young population

Answer 76

Answers:
1. 4,000
2. 65
3. twists
4. tenderness
5. trauma
6. bell-clapper
7. likely
8. puberty
9. fasted
10. spinal

Question 77

Fournier’s Gangrene
- Form of necrotizing fasciitis affecting _______(1)
- Most commonly in older men & frequently associated comorbidities = _______(2).

• Minor genital trauma = inciting event → rapid widespread inflammation, infection, & ultimately polymicrobial _______(3)
• Often present w/ already est’d septic shock warranting emergent status for _______(4)
  
  • priorities = fluid resuscitation & broad-spectrum antibiotic thx (staphylococci, streptococci, _______(5), & anaerobes)
  • Surgical mgmt consists of incision, drainage, & debridement of affected _______(6)
  • _______(7) oxygen thx = employed (not 1st)

Answer 77

Answers:
1. genitalia
2. DM (Diabetes Mellitus), morbid obesity, & immune suppression.
3. sepsis
4. surgery
5. enterobacteriaceae
6. tissue
7. Hyperbaric