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424 Cards in this Set
- Front
- Back
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there are ... among endocrine organs
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no anatomic connections
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hormone are secreted into the..and then the...
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intersittial space and blood
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three types of hormones
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protein, steroids amino acid derivatives
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protein hormones are otherwise called
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peptide hormones
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types of protein hormones
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insulin TSH, glucagon ACTH
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protein hormones are synthezied in
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endoplastic reticulum
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steroid hormones are synthesized from
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cholesterol
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ex of steroid hormone
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acth, cortisol
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steroid hormones are not
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stored
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amino acid derivatives are otherwise called
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amines
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amines are synthesized from
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tyrosine
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ex of amine hormones
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catecholamines, norepi
thyroid |
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neurontransmitters are released by
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axons in the synaps
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endocrine hormones are released
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into the blood and travel to target organ
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neuroendocrine hormones are secreted
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secreted by neurons into circulation influencing cellular function at another location
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paracrine hormone are released from and produce an effect on
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hormone is released from 1 cell & produces effect on a neighboring cell of a different type often in same organ via interstitial space
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autocrine hormones produce
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hormone produces effect on same cell that released it
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peptides secreted by cells into the ECF which can function as autocrines, paracrines, or endocrine hormones…i.e. interleukins are otherwise called
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cytokines
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water soluble hormones are dissolved in..and are transported to...
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Water soluble hormones dissolved in plasma & transported to target tissue via the interstitial space
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plasma proteins bound hormones are
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Plasma protein bound such that less than 10% of hormone is free in solution; reservoir
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two examples of water soluble hormones
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peptide, catecholamines
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two examples of plasma protein bound hormone
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steroid , thyroid
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metabolic clear. rate
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Metabolic clearance rate = rate of disappearance of hormone from the plasma/concentration of hormone per ml plasma
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hormone clearance occurs in four ways
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Metabolic destruction by tissues
Binding with tissues Excretion into bile by the liver Excretion into the urine by the kidneys |
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how many receptors are there per cell
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2000-100,000 receptors per cell
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receptors can occur in three places
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Cell membrane surface
Cytoplasm Cell nucleus |
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...hormones are responsible for negative feedback
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tropic
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two tissue types: pancreas
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acini, islet of langerhans
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...or lobules are divided by connective tissue in the pancrease
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acini
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acini are connected to
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pancreatic duct
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pancreatic duct is connected to
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duodenum
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number of islets of langerhands
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1-2 mill
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diameter and arrangment of islets of lang.
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.3mm arranged around a capillary
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4 type of cells in islets of langerhans
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alpha, beta, delta,pp
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60% of islets in the middle which secrete insulin are called
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beta
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25% of islet cells that secrete glucagon
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alpha
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10% of islet cells that secrete somatostatin
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delta
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1% of islet cells that secrete peptide
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pp
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1/2 life of insulin, clear. rate
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½ life of 6 minutes (3-8); cleared in 10-15 minutes
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insulin structure
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51 amino acids
2 amino acid chains connected by disulfide linkages |
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insulin increases the rate of glucose transport into resting muscle by
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Increases the rate of glucose transport into the resting muscle cell by 15 times
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insulin circulates mostly
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Circulates mostly unbound to protein
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insulin mode of action
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Insulin binds to & activates membrane receptor protein & the activated receptor causes the effect
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Resting muscle membrane only slightly permeable to glucose in absence of insulin except:
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Moderate - heavy exercise causes contraction which makes fibers more permeable to glucose
Following a meal with blood glucose level high and large amounts of insulin secreted there is rapid transport of glucose & preferential use of glucose by the muscle fibers so ↑ rate of glucose transport 15 X |
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net result of effect of insulin on cho metabolism
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Net result; glycogen can ↑ to a total of 5-6% of liver mass or 100 gm of stored glycogen
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insulin increases activity of
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Insulin increases activity of enzymes leading to glycogen synthesis
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insulin enhances glucose uptake from blood leading to increased activity of..by liver
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Insulin enhances glucose uptake from blood → liver by ↑ glucokinase activity
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insulin inactivates liver...
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Insulin secreted inactivates liver phophorylase
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during hypoglycemia, glycogen is split into by...by activation of..
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Glycogen is split into glucose with activation of phosphorylase
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during periods of hypoglycemia, ..is activated
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Glucose phosphatase now activated by lack of insulin removing the phosphate radical from glucose
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excess glucose is converted to...
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Excess glucose converted to fatty acids → triglycerides → LDL → adipose
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inhibition of gluconeogenesis leads to
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↓ amount & activity of liver enzymes
↓ release of amino acids from muscle & other tissues |
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in the brain, Insulin ... for glucose uptake & utilization
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isnt necessary
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in the brain, glucose
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Glucose is the only substrate used for energy
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below levels of...glucose in the CNS, symptoms develop including
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Below levels of 50 mg/100ml CNS symptoms develop including
Irritability Syncope Seizures Coma |
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glucose pathway to fat
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Glucose → pyruvate → acetyl CoA → fatty acids → triglycerides → storage fat
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insulin promotes fat storage by
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inhibition of lipase
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Insulin promotes glucose transport via cell membrane into
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fat cells
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Insulin deficiency... storage of fat and increases the use of fat for energy
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prevents
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lipolysis of fat leads to (3)
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↑ cholesterol & phospholipid concentrations
ketosis acidosis |
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Lack of insulin results in .. & increased amino acids in the blood
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protein depletion
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.. of protein results in increased urea excretion
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catabolism
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Insulin functions ... with GH to promote growth
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synergistically
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insulin promotes insulin...and..
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synthesis and storage
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Glucose transporters permit rate of glucose influx proportional to..
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blood concentration
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Glucose → .. → ATP
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G-6 phosphotate
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ATP causes ... to close (sulfonylureas work here)
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K channels
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during insulin secretions ...open & intracellular... causes fusion of insulin vesicles with c.m.
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ca channels, ca
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Insulin released to ECF by ....
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exocytosis
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(5) causes of decreased insulin secretion
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leptin, a adrenergic activity, hypoglycemia, somatostatin, fasting
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..hormones increase insulin secretion
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gi hormones (gastrin), cortisol, growth hormone
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...adrenergic stimulation causes increased insulin secretion
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b adrenergic
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2 ex of sulfunarea that causes increased insulin secretion
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glyburide, tolbutamide
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Insulin promotes utilization of CHO & depresses utilization of .. so…..
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Insulin promotes utilization of CHO & depresses utilization of fats so…..
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↓ insulin causes fat utilization except by
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brain
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Blood glucose primarily controls the switch between
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CHO & fat
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other hormones involved in the switch bw cho and fat
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Other factors involved in the switch are:
Growth hormone Cortisol Epinephrine Glucagon |
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structure of glucagon
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polypeptide
29 amino acids M.W. 3485 |
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glucagon increases blood glucose concentration by
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Glycogenolysis & gluconeogenesis
Opposes insulin Hyperglycemic hormone Lipolysis & inhibits triglyceride storage |
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structure and half life of somatostatin
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Polypeptide
14 amino acids 3 min |
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(4) increase secretion of somatostatin
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Increased blood glucose
Increased amino acids Increased fatty acids Increased GI hormones |
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somatostatin decreases (3)
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↓ secretion of insulin & glucagon
↓ GI motility (stomach, duodenum, gall bladder) ↓ secretion & absorption in GI tract |
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primary role of somatostatin is to
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Principle role is to increase the length of time food is in GI tract & prevent rapid exhaustion of food nutrients
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somatostatin is chemically identical to
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Chemically identical to growth hormone inhibitory hormone secreted in hypothalamus which inhibits GH secretion in anterior pituitary
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liver acts as a buffer for
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glucose control
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..and..provide feedback control
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insulin and glucagon
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In severe hypoglycemia the hypothalamus is stimulated by the SNS such that ... from the adrenal medulla causes additional glucose to be released from the liver
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epinephrine
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over a period of hours to days during hypoglycemia..
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Over a period of hours to days, GH & cortisol are secreted due to hypoglycemia & this decreases the rate of glucose utilization by most cells of the body shifting to fat utilization
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glucose is the only nutrient normally used by (3)
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Glucose is the only nutrient normally used by the brain, the retina, and the germinal epithelium of the gonads.
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Glucose exerts a .... in the ECF which could cause cellular dehydration
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high osmotic pressure
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Severe hyperglycemia causes ...(2)
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glycosuria and an osmotic diuresis
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ave age of onset of IDDM
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14
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IDDM: dehydration occurs in ICF because of ..in ECF because of ..
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Dehydration
ICF: 2° increased ECF osmolarity ECF: 2° osmotic diuresis |
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normal threshold for glycosuria
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180 mg/dl
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diagnosis of IDDM is based on
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↑ FBS greater than 126-140 mg/dl or random BS > 200 mg/dl
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autonomic neuropathy is present in ..percent of diabetics
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20-40
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...is a complication of DM that is associated with the highest mortality
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nephropathy
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incidence of stiff joint syndrome in DM
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30-40%
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preop dose for bolus technique
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Preop: 5% dextrose in water at 1.5 ml/kg/hr + ½ usual am NPH dose
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1 unit of regular insulin given to an adult usually lowers the plasma glucose by ....mg/dl
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1 unit of regular insulin given to an adult usually lowers the plasma glucose by 25-30 mg/dl
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cont infusion of insulin
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Preop/intraop/postop: 5% dextrose in water at 1 ml/kg/hr + regular insulin in units/hour = plasma glucose/150
150 |
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10-15 units of regular insulin can be added to 1L 5% dextrose in water & infused at a rate of... unit/hour/70 kg or can infuse... units of regular insulin in 250 NaCl via separate lines for greater flexibility adjusting to above formula.
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1 unit/hr/70 kg
50 units |
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hyperthyroid patients can be chronically...and vasodilated
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hypovolemic
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hypothyroid patients are more susceptible to the ...effect of agents
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hypotensive
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pts with cushings tend to be volume overloaded and have
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hypokalemic metabolic alkalosis
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drugs to be avoided by pts with pheochromocytoma are
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stimulatants-ephedrine, ketamine, hypoventilation
potentiate arrythmic effect of catecholamines...halothane inhibit the parasympathetic system..pancuronium release histamine..artucurium, morphine |
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key to management of patients with carcinoid syndrome
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to avoid techniques that cause the tumor to release vasoactive substances
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endocrinologic effects of insulin on liver
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promotes glycogenesis
increases synthesis of triglycerides, cholesterol, vldl increases protein synthesis inhibits glycogenolysis inhibits ketogenesis inhibits gluconeogenesis promotes glycolysis |
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insulin effects on muscle
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promotes protein synthesis
increases amino acid transport stimulates ribosomal protein synthesis promotes glycogen synthesis increases glucose transport enhances activity of glycogen synthetase inhibits activity of glycogen phosphorylase |
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insulin effects on fat
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promotes triglyceride storage
induces lipoprotein lipase, making fatty acids available for transport into fat cells increases glucose transport into fat cells, thus increasing availability of a glycerol phosphate for triglyceride synthesis inhibits intracellular lipolysis |
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Type III DM
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secondary to genetic defects
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type IV DM
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gestational
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blood glucose runs..lower than plasma
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12-15%
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lactic acidosis is defined by a lactate level
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above 6 mmol/l
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ketone body structure
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acetoacetate and b-hydroxybuteric acid
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DKA is an ...gap metabolic acidosis
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anion
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most common cause of DKA
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infection
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usual first sign of DM in children
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infection
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when plasma bs level reaches...during therapy for DKA, dextrose should be added
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250
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....acidosis is not a features of HNKC
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ketoacidosis
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severe hyperglcemia causes,....,with each 100 mg/dl increase in plasma glucose, lower plasma sodium concentration by .... meq/L
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hyponatremia...1.6
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counterregulatory failure
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dm patient are not able to secrete glucagon and epi in response to hypoglycemia
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clinical signs of diabetic autonomic neuropathy
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hypertension
painless myocardial ischemia orthostatic hypotension lack of heart rate variability reduced hear rate in response to atropine and propranalol resting tachycrdia early satiety neurogenic bladder lack of sweating impotence |
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primary goal of intraoperative blood surgar mangement is to
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avoid hypoglycemia
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patients who take ..or...are at an increased risk of allergic reactions to protamine sulfate
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NPH/protamine zinc insulin
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pts on NPH or protamine zinc sulfate who require protamine sulfate should first receive a
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test dose
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diatery iodine is absorbed by the....and converted to
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gi tract, iodide ion
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iodide ion is transported into the
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thyroid
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inside the thyroid, iodide is oxidized back to iodine which is bound to
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amino acid tyrosine
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result of oxidation of iodide into iodine in the thyroid is the formation of
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t3 triiodothyronine
t4- thyroxine |
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t3 and t4 are bound to
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proteins stored in the thyroid
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t3 is ...protein bound and ..potent than t4
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less protein bound more potent
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the thyroid releases more or less T4 than t3
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more t4
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most t3 is formed
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peripherally from deiodination of t4
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three parts of the feedback mechanism of thyroid
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autoregulation...thyroid iodine concentration
anterior pituitary..thyroid stimulating hormone TSH hypothalmus...thryotropin releasing hromone |
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thyroid hormone controls growth and metabolic rate by
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increasing fat and carb metabolism
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how does the thyroid increase minute ventilation
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by increasing oxygen consumption and co2 production through an increase in the metabolic rate
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how does the thyroid increase hear rate and contractility
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from an aleteration in arenergic receptor physiology and other internal protein alterations.
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resting HR recommendations for hyperth.
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85
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titration of an...infusion is used hemodynamic control of hyperthyroidism
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esmolol
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...possess anti thyroid activity at high doses
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thiopental
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NMBA should be used cautiosly with pts that are hyperthyroid because thyrotoxitosis is associate with
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myopathy and mgravis
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hyperthyroidism does/not effect MAC
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no
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usual onset for thyroid storm
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6 to 24 hrs post op
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unlike MH, thyroid storm is not associated with
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acidosis, muscle rigidity, elevated CK
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treatment for thyroid storm
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esmolol IV propranalol, .5 mg increments
hydration cooling propylthiouracil 250-500 mg/hr q6 IV or by NG followed by sodium iodide, I IV/12 hrs cortisol 100mg q 8 to prevent associated adrenal suppresion |
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complications of subtotal thyroidectomy
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recurrent laryngeal nerve palsy will result in hourseness, unilateral
or aphonia and stridor- bilaterall Hematoma formation from collapse of trachea in pts w/tracheomalacia. difficult intubation because of neck dissection hypoparathyroidism from unintentinal removal of the parathyroid gland will cause acute hypocaclemia w/ in 12-72 hrs unintential pneumo because of neck exploration |
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diagnosis of hypothyroidism is done by
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low free T4
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primary hypoth is differentiated from secondary disease by
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elevation of TSH
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treatment of myxedema coma
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loading dose of t3 or 4 300-500 mg of elvothyroxine in pts wout heart disease followed by maint. 50 mg of levo per day. and hydrocotisone to treat coex. adrenal suppresion.
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patients with uncorrect hypothyroidism with a t4 level below...should not undergo elective surgery and should be treated with thyroid hormone prior to emergency surgery
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1 mg/dl
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....patients are very prone to drug induced respiratory depression
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hypothyroid
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..pts fail to respond to hypoxia with increased minute ventilation
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hypothyroid
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hypothyroid pts have.....and should be premedicated with H2 antagonists and regland
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decreased emptying time
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half life of T4
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8 days
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euthyroid pts may receive the dose of medication morning of surgery
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full dose
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recommended induction agents for hypothyroid patients is
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ketamine
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in cases of refractory hypotension with hypothyroid pts,...should be considered
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adrenal insufficiency and congestive heart failure
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hypothyroidism does/not effect MAC
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does not
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potential problems of hypothyroidism
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anemia, difficult intubation because of large tongue, hypothermia from low metabolic rate, hypoglycemia, hyponatremia
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recovery in hypothyroid patients may be delayed because of
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delayed drug biotransformation
hypothermia respiratory depression |
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good choice of pain reliever for hypothyroid patients is
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toradol
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...principle regulator of calcium homeostatsis
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parathyroid
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...or calcium is ionized an unbound
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60
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causes of primary hyperparathyroidism are
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adenoma, carcinoma, hyperplasia of the parathyroid glan
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acceptable serum ca
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less than 14 mg/dl, 7 meq/L 3.5 mol/L
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IV tx for hypercalcemia
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IV bisphosphonates Pamidronate, etidrontate. Plicamycin, glucosteroids, calcitonin, dialysis.
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hypoventilation should be avoided as..increases ionized calcium
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acidosis
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in pts with parathyroid disease, response to ...may be altered because of prexisting muscle weekenss caused by the effectsof ca on neuromuscular junction
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NMB
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cardiovascular effects of hyperparathyroidism
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hypertension, ventricular arrythmias, ECG changes shown my a short QT interval
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Renal effects of hyperparathyroidism
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impaired renal concentrating ability , hyperchloremic metabolic acidosis, polyuria, dehydration, polydipsia, renal stones, renal failure
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gi effects of hyperparathyroidism
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ileus, nausea, vomiting, peptic ulcer disease, pancreatitis
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muscl effects of hyperparathyroidism
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muscle weakness, osteoporosis
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neurologic effects of hyperparathyroidism
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mental status changes, delirium etc
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cardiovascular effects of hypoparathyroidism
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hypotension, congestive heart failure, ECG changes, Prolonged Qt Interval
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musculoskeletal effects of hypoparathyroidism
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muscle cramps, weakness
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nurologic effects of hypoparathyroidism
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neurologic irritability, largyngospasm, inspiratory sturdor, tetany seizures, periororal paresthesia, dementia
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a ...drop in serum albumin, causes a...drop in total serum ca
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1 g/dl or serum albumin drop causes a .8 mg/dl decrease in serum ca
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causes of hypoparathyroidism and hypcalcemia
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acute pancreatitis
vit D deficiency hypomagnesia renal failure |
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5% albumin in pts with hypocalcemia should be ...because
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avoided because it binds ca and may lower ionized ca
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sodium bicarbonate or ...from hyperventilation will further decrease ca levels
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acidosis
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three functional divisions of the pituitary ar
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Anterior (adeno-)
Posterior (neuro-) Pars intermedia |
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how is the pituitary related to the hypothalmus
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hypothalmus stalk
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peptide hormones from the hypothalmus are
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ACTH
TSH GH LH FSH Prolactin |
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aka somatotropin
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growth hormone
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gh is made up of ..amino acid
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191
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metabolic effects of growth hor
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↑ rate of protein synthesis in most cells
↑ mobilization of fatty acids ↓ rate of glucose utilization |
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effects of gh on amino acid
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↑ Intracellular amino acid concentration
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GH enhances conversion of fatty acids → ..... → used for energy
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acetyl- CoA
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ketone effects of liver
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fatty liver
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gh effects on glucose and insulin
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↓ glucose uptake in skeletal muscle & fat
↑ glucose production by the liver ↑ insulin secretion |
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gh effects on gluose/insulin
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There is adequate insulin
There is adequate CHO in the diet ** partly due to the need for energy for metabolism of growth |
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how does gh effect bone growth
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↑ Deposits of protein by chondrocytic & osteogenic cells
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how does deposition of new bone occur occur w/gh
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Deposition of new bone 2° conversion of chrondrocytes to osteogenic cells
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how does gh effect bone length
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GH causes ↑ bone length at epiphyseal cartilages
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growth hormone secretion is affected by
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Pulsatile secretion related to:
Nutritional status Level of stress |
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GH causes growth only when
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There is adequate insulin
There is adequate CHO in the diet |
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how does gw effect bone growth
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↑ Deposits of protein by chondrocytic & osteogenic cells → bone growth
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growth hormone causes bone growth due to Deposition of new bone 2° conversion of
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chrondrocytes to osteogenic cells
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gh increases bone length by two mechanisms
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GH causes ↑ bone length at epiphyseal cartilages
Osteoblasts in bone periosteum & some bone cavities deposit new bone on surfaces of old bone then osteoclasts remove old bone. GH strongly stimulates osteoblasts |
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...is Secreted by ventromedial nucleus of hypothalamus
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ghrh
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ghih aka
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somatostatin
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Other hormones secreted by hypothalamus also increase rate of GH secretion
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Catecholamines
Dopamine Serotonin |
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↓ secretion of all anterior pituitary hormones
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panpituitarism
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acquired gh deficiency is usually due to
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Acquired (usual 2° pituitary tumors that destroy the gland)
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xxx: if excess GH secretion before epiphyses fuse
xxx: if excess GH secretion after epiphyses fuse |
Gigantism: if excess GH secretion before epiphyses fuse
Acromegaly: if excess GH secretion after epiphyses fuse |
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(3) signs of gh excess
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Overgrowth of tissue
Peripheral neuropathy Glucose intolerance |
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panhypopituitarism can result from gh excess because
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tumor will cont to grow untill it explodes
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Presence of hoarseness or stridor suggests
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laryngeal involvement
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acromegaly leads to vocal cord involvement because
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of stretching of other structures
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vasopressin, aka..aka
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ada..pitressin
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two posterior pituitary hormones
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vasopressin, oxytocin
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vasopressin and oxytocin are released from the ..but made in the
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made in hypothalmus released from the posterior pituitary
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vasopressin is Secreted in xxx(5/6) & xxx (1/5) nuclei of hypothalamus
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supraoptic
paraventricular |
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vasopressin is secreted in response to
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Secreted in response to osmotic stimulus (osmoreceptors in hypothalamus)
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how does blood volume and plasm and osmolarity effect secretion of vasopressin
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↑ plasma osmolarity
↓ blood volume |
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secretion of vasopressin results in (2)
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Secretion results in insertion of aquaporins in cell membrane & ↑ permeability of collecting ducts & tubules to water
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w/out vasopressin there would be large amounts of ..urine
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dilute
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...% body water in males...% females
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60% male, 50% female
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ICF is ..% of body water
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40
|
|
|
ECF is ..% of body water
|
20
|
|
|
Intravascular is ..% body weight
|
5%
|
|
|
Interstitial is...% of body weight
|
15%
|
|
|
central of ...DI occurs from
|
Neurogenic, destruction from posterior pituitary
|
|
|
acquired or nephrogenic di occurs from
|
Chronic renal disease
Hyperkalemia & hypocalcemia Sickle cell disease |
|
|
symptoms of DI
|
Polyuria & polydipsia in absence of hyperglycemia
|
|
|
tx for central and nephrogenic DI
|
Central : ADH as DDAVP
Nephrogenic: fluid replacement & Rx underlying cause |
|
|
which antibiotic has a side effect of DI
|
tetracyline
|
|
|
SIADH causes
|
Causes
Intracranial tumors Hypothyroidism Porphyria Carcinoma of the lung (esp. undifferentiated small cell) After major surgery |
|
|
SIADH symptoms
|
Dilutional hyponatremia
↑ urine Na & urine osmolarity |
|
|
(3) tx of SiADH
|
IV NaCl (hypertonic if neuro sx)
Demeclocycline |
|
|
causes of SIADH
|
Intracranial tumors
Hypothyroidism Porphyria Carcinoma of the lung (esp. undifferentiated small cell) After major surgery |
|
|
how does vasopressin increase BP
|
↑ BP d/t constriction of arterioles at high levels of ADH
|
|
|
adh secretion can go up to ..x normal with a blood volume decrease of 15-25%
|
50
|
|
|
adh inhibition results from
|
overstretching of atria stretch receptors
|
|
|
adrenals are...grams/each
|
4
|
|
|
adrenals are located on the..of each kidney
|
superior pole
|
|
|
two divisions of adrenal
|
cortex medulla
|
|
|
3 parts of adrenal cortex
|
Zona glomerulosa
Zona fasciulata Zona reticularis |
|
|
part of adrenal cortex that stimulates aldosterone
|
zona glomerulosa
|
|
|
part of adrenal cortex that Secretes glucocorticoids cortisol & corticosterone & small amount of androgens & estrogens
|
zona fasciculata
|
|
|
...secretes hormones from zona fasciculata
|
acth
|
|
|
deepest layer of the adrenal cortex
|
zona reticularis
|
|
|
.....Secretes androgens (DHEA), small amounts of estrogens & glucocorticoids via ACTH
|
zona reticularis
|
|
|
secretion of glucocorticoids is stimulated by
|
acth from anterior pituitary
|
|
|
..% of mineralcorticoids is
|
aldosterone
|
|
|
aldosterone is made from
|
LDL in plamsa
|
|
|
Increases sodium reabsorption & potassium secretion by renal tubules
|
aldosterone
|
|
|
No aldosterone → ↑salt lost in urine →.... volume & sodium → dehydration → death
|
decreased ECF
|
|
|
effects on potassium by excess aldosterone
|
hypokalemia
|
|
|
excess aldosterone causes...mild..
|
alkalosis
|
|
|
excess aldosterone effects of sodium
|
diuresis
|
|
|
two primary regulators of aldosterone
|
angiontensin 2 and k
|
|
|
increased ECF potassium causes
|
increased aldosterone
|
|
|
renin is released in response to
|
decreased blood volume
|
|
|
prednisone is ..x as potent as cortisol
|
4
|
|
|
methylprednisone is...x as potent as cortisol
|
5
|
|
|
dexamethesone is..x as potent as cortisol
|
30
|
|
|
...mg of cortisol is secreted daily
|
20
|
|
|
95% of corticosteroids are
|
cortisol
|
|
|
% of glucocorticosteroids are bound to plasma protein
|
90 to 95
|
|
|
aldosterone is ..% bound
|
60
|
|
|
during periods of stress...are broken down to
|
proteins are broken down to make amino acids available for synthesis
|
|
|
tissue effects during periods of stress are
|
Release histamin bradykin from damage cells (gluc. Wil block early stages)
Erythema Increased cap perm Wbc infiltratin (decrease and attentuate fever secondary to decreased interleukin 1 from wbc) Growth of fibrous tissues |
|
|
corticotropin releasing hormone is released from the
|
hypothalmus
|
|
|
acth is released from the
|
anterior pituitary
|
|
|
cortisol synthesis occurs after acth stimulation in the
|
adrenal cortex
|
|
|
h-p adrenal axis negative stimulation occurs after the release of..from
|
cortisol from the adrenal cortex
|
|
|
causes of primary aldoseteranism/minel.c excess
|
Unilateral adenoma
Bilateral hyperplasia Carcinoma of adrenal |
|
|
causes of secondary aldosteranism
|
Stimulation of aldosterone secretion by affecting renin-angiotensin system
|
|
|
signs of mineralcorticoid excess and aldosteranism
|
HTN
Hypervolemia Hypokalemia Muscle weakness Metabolic alkalosis Polyuria Decreased ionized calcium → tetany |
|
|
causes of mineralcorticoid deficiency
|
Atrophy or destruction of adrenals
Unilateral adrenalectomy Diabetes mellitus Heparin therapy |
|
|
signs of mineralcorticoid deficiency
|
Hyperkalemia
Acidosis hypotension |
|
|
..is given to correct mineralcorticoid deficiency
|
fludrocortisone
|
|
|
primary adrenal insufficiency is caused by
|
addisons disease
|
|
|
most commons cause of glucocorticoid excess is
|
cushings disease
|
|
|
...and....osone can not be given iv
|
prednisone and cortisone
|
|
|
highest osone sodium retaining potency is of...
|
fludocortisone 125 x that of cortisol
|
|
|
duration of action of dexamethasone
|
36-54 hrs
|
|
|
endogenous osone can be given to up to...in 24 hrs
|
100 mg
|
|
|
...% of adrenal medulla is epi
|
80
|
|
|
epi can increase metabolic rate up to..x normal
|
100
|
|
|
...% of the medulla is nor epi
|
20
|
|
|
the adrenal medulla is emryonianically....ted to the adrenal cortex
|
unrelated
|
|
|
the release of at the nervous system ganglion stimulates release of hormones from the adrenal medula
|
acetylcholine
|
|
|
3 hormones from the adrenal medulla
|
norepi , epi, and domapine
|
|
|
90% of pheocrhomocytomas are in the
|
adrenal medulla
|
|
|
% of pheocrhomocaytomas are malignant
|
10-15
|
|
|
age at presentation of pheocrhomacytoma
|
30-50
|
|
|
signs of pheocrhomocytoma
|
Sx: HTN, diaphoresis, headache, palpitations, weight loss (triad = diaphoresis, tachycardia, headache in the hypertensive patient)
Hypovolemia from sustaine hypertension and concentrated HCT |
|
|
tx for pheocrhomacytoma is
|
surgical excision
|
|
|
beta blockade methodology for pheochromacytoma
|
only after alpha blockade has been established
|
|
|
why is phenoxybenxamine given for pheocrhomacytoma
|
alpha blockade, will prevent vasoconstriction and allow for fluid volume replacement
|
|
|
phenoxybenzamine is given
|
po
|
|
|
with pheocrhomacytomas avoid
|
ketamine, procaine halothane
|
|
|
multiple endocrine neoplasia is a
|
autosomal dominant multiglandular disorder
|
|
|
MEN 1 type A is also called
|
sipple syndrome
|
|
|
marfans can be caused by..MEN TYPE
|
2b
|
|
|
goiter can present as a..on ausculation
|
bruit
|
|
|
colloid makes up..% of the thyroid gland
|
30
|
|
|
glycoprotein..is a major constituent of the thyroid gland
|
thyroglobulin
|
|
|
parafollicular cells in the thyroid will secrete
|
calcitonin
|
|
|
each molecule of thyroglobulin contains..amino acids which combine with iodine to form
|
70...thyroid hormone
|
|
|
thyroid hormones form in the..and are stored in the...
|
thyroid globulin, stored in the collioid of the follicle
|
|
|
thyroid gland can store up to..of hormone
|
2-3 ms
|
|
|
...% of thyroid hormone is
|
t4
|
|
|
normal serum level and free t4
|
Normal total serum level = 5-12 mcg/dl; free T4 = 1-2 mg/dl
|
|
|
t4 half life is
|
6-8 days
|
|
|
t4 is also called
|
thyroxine
|
|
|
t3 is..%
|
9
|
|
|
t3 level
|
Normal = 80-200 ng/dl
|
|
|
t3 half life
|
24 hrs
|
|
|
need...of diet iodine per week
|
1 mg
|
|
|
4 steps of thyroid hormone synthesis
|
4 Step process:
Iodide is actively transported into the thyroid Iodide (I-) is oxidized to the active form iodine (I) Iodine is incorporated into tyrosine residues that are bound to thyroglobulin Iodinated tyrosine molecules are coupled forming T-3 & T-4 |
|
|
thyroid major protein molecule
|
thyroid binding globulin
|
|
|
estrogens and methadone cause and major tranquilizers cause...levels of thyroid binding proteins and t3/t4
|
high
|
|
|
glucocorticoids, androngens and dianzalol, asparginase cause..leves of..thyroid binding hormones and t3/t4
|
low
|
|
|
hypothyroidism causes ..levels of t3t4 and ..levels of tsh
|
high tsh, low t3 t4
|
|
|
hyperth causes ..levels of tsh and..levels of t3 t4
|
low tsh high t3 t4
|
|
|
hypo/hyper causes..levels of binding proteins
|
normal
|
|
|
thyroid hormone negative feed back loop
|
TRH is released from hypoth
TSH from ant. pit TSH stim gland to secrete t3 and t4 free unbound t3 t4 will provide the negative feedback to an. pit |
|
|
....t3 and t4 will provide the neg. feedback to the ant. pituitary
|
free unbound
|
|
|
how do thyroid hormones effect CHO metabolism
|
↑ glycolysis
↑ gluconeogenesis ↑ absorption from GI tract ↑ insulin secretion |
|
|
how is fat metabolism effected by thyroid hormones
|
Lipids mobilized from adipose which decrease fat stores & increase fatty acids in plasma thereby increasing fatty acid oxidation by cells
↓ cholesterol, phospholipids, & triglycerides |
|
|
systolic bp goes up..mm hg with increased thyroid stim
|
10-15
|
|
|
there is an increase in...receptors with thyroid stim
|
beta receptors
|
|
|
effects on adipose and muscle tissue by thyroid hormone are
|
catabolic
|
|
|
t4 is increased..in hyperth pts
|
90%
|
|
|
normal tsh
|
0.4-5 mul/l
|
|
|
best test for thyroid hormone at the cellular level
|
tsh
|
|
|
95 % of hypoth is
|
primary
|
|
|
primary hypoth is usually caused by
|
surgical tx, radioactive iodine tx
|
|
|
secondary hypoth is caused by
|
pituitar or hypothalmic imbalance
|
|
|
graves dis and hashimotos both cause
|
goiters
|
|
|
end cardiac effects of hypoth are
|
cardiomegaly (severe cases)
Percardial effusions Impaired baroreflex |
|
|
decreased blood volume in hypoth is caused by
|
increased peripheral resistance
|
|
|
how does hypoth cause CAD
|
increase in triglycerides and cholesterol
|
|
|
renal se of hypoth
|
hyponatremia, and impaired free water excretion
|
|
|
resp se of hypoth
|
↓ Maximum breathing capacity, diffusion capacity, & ventilatory response to hypoxia & hypercarbia
|
|
|
ms se of hypoth
|
Prolonged relaxation phase in deep tendon reflexes
|
|
|
anes. gi implications of hypoth
|
decreased gi function and aps risk
|
|
|
overt hypoth is diagnosed by
|
Marked ↓ T 4 & mean TSH of 90 mU/L
|
|
|
subclinical hypoth is diagnosed by
|
T 4 is normal with ↑ TSH (mean = 18 mU/L) = (few symptoms)
|
|
|
l thyroxine onset, peak and half life
|
onset 6-12 days, peak is 10 days, half life is 7.5 days
|
|
|
hypoth airway implications
|
edema of vocal cords and goiter
|
|
|
iv t3 has onset of
|
6 hrs
|
|
|
one should...steroid cov in hypoth pts
|
question
|
|
|
good drug for IV induction in hypoth pts
|
ketamine
|
|
|
myxedema coma tx
|
t3 and t4
|
|
|
99% of hyperth is caused by
|
Grave’s disease
Toxic nodular goiter Toxic adenoma |
|
|
clinical manifestations of hyperth are
|
Anxious, restless, hyperkinetic
Skin is warm & moist & face flushed Heat intolerance, diaphoresis Muscle weakness, wasting (proximal limbs) Fatigue but unable to sleep Osteoporosis Weight loss despite ↑ caloric intake Hyperactive reflexes, tremor |
|
|
2 antithyroid drugs are
|
Propylthiouracil (PTU)
Methimazole (Tapazole |
|
|
immediate lowering of thryroid hormones preop occurs w
|
inorganic iodide
|
|
|
..can be used preop in hyperthyroid patients
|
beta blockers
|
|
|
complications of thyroid surgery are
|
Hemorrhage with tracheal compression
Recurrent laryngeal nerve damage Inadvertent removal of parathyroids |
|
|
tx of thyroid storm is
|
Potassium iodide
Propylthiouracil Beta blocker Peripheral cooling, IV fluids Glucocorticoids |
|
|
emergency cases of hyperthyroidism
|
Potassium iodide
Propylthiouracil Beta blocker Peripheral cooling, IV fluids Glucocorticoids |
|
|
anticholinerics are..with hyperth
|
avoided
|
|
|
midazolam is..with hyperth
|
used
|
|
|
thiopental has...thyroid activities
|
anti
|
|
|
dose of NMB must be...with hyperth
|
lowerered, mgravis
|
|
|
parathyroid...cells secrete hormone
|
chief
|
|
|
parathyroid polypeptide has..amino acids
|
84
|
|
|
pth and calcium
|
Bone resorption of calcium
Kidney ↑’s reabsorption of calcium (distal tubules) & ↓ reaborption of phosphate Also intestinal absorption indirectly by vitamine D activation |
|
|
pth and calcium/phosphate levels
|
Secretion causes ↑ plasma calcium levels & ↓ plasma phosphate levels along with ↑ excretion of phosphate in the urine
|
|
|
main parathyroid hormone effects
|
Main physiologic effect is to maintain calcium homeostasis by tight feedback system according to plasma calcium levels
|
|
|
pth release is suppressed by
|
vit d hypercalcecmia and severe hypomagnesia
|
|
|
catecholamines ...pth rlease
|
increase
|
|
|
calcitonin is a peptide hormone with ..
|
32 amino acids
|
|
|
50% of calcium is
|
ionized
|
|
|
body makes grams of ca
|
1,100
|
|
|
..% of ca is protein bound
|
41
|
|
|
...%of ca is complexed to ions
|
9%
|
|
|
total plasma ion ca
|
9-10 mcg/l 1.2 mml/l
|
|
|
vit d increased
|
gi calcium and phosphte abs
|
|
|
calcitonin decrases both
|
calcium and phosphate renal reabs
|
|
|
Congenital disorder where kidneys can’t respond to PTH
Patients will have mental retardation, calcification of basal ganglia, obesity, & structural abnormalities |
pseudhypoparathyroidism
|
|
|
signs of hypoparathyroidism
|
Hypocalcemia
Chvostek’s sign Trousseau’s sign Paresthesias Convulsions Irritability & psychosis Muscle cramps Decreased myocardial contractility, first degree AV block Intestinal malabsorption |
|
|
tx of hypoparathyroidism
|
High calcium diet with vitamin D
Thiazide diuretics to decrease renal clearance of calcium Acute hypocalcemia treated with 10 ml of 10% calcium gluconate IV |
|
|
diuretics will cause decreased renal cl. of ca
|
thiazide
|
|
|
resp tx of low ca levels
|
Avoid hyperventilation as alkalosis will further ↓ calcium levels as it causes ↑ binding to protein & ↓ in free, ionized calcium
|
|
|
pts with low ca levels should not receive...albumin
|
5% as it will bind
|
|
|
blood transf. to pt with low ca levels will cause
|
lower ca levels because citrate in blood products will bind to ca
|
|
|
* most common presenting symptom of multiple endocrine neoplasia (MENS) type I with...ca levels
|
benign parathyroid adenoma, high high levels
|
|
|
secondary hypeparathyroidism is caused by
|
low ca levels from other sources
|
|
|
Ectopic hyperparathyroidism =
|
pseudohyperparathyroidism
|
|
|
symptoms of high ionized ca
|
↓ neuromuscular excitability
Muscle weakness, decreased muscle tone Fatigue Mental confusion, depression, coma (with levels > 15 mg/dl |
|
|
ionized ca levels above will result in coma
|
15 mg/dl
|
|
|
temporizing tx of hyperparathyroidism
|
Hydration with IV saline
Loop diuretics to inhibit calcium reabsorption in L of H |
|
|
...diuretics will inhibit ca reabsorb
|
loop
|
|
|
following the removal of a diseased gland, ca levels will normallize in
|
3 -4 days
|
|
|
anes. implications of hyperparathyroidism
|
Maintain adequate hydration & urine output
Care with sedation & avoid ketamine 2° mental status changes & somnolence Consider possibility of co-existing renal disease with drug selection Monitor TOF, EKG, BP (naturally!) |
|
|
..% of people with type I DM have tmp instability
|
30
|
|
|
sulfanaryeas and metformin should be...before surgery because
|
dc because of the long half lives
|
|
|
why are hyperth pts prone to an exagerated response to induction
|
because they are chronically vasodilated and hypovolemic
|
|
|
why are hypoth pts more prone to the hypotensive effect of anes. agents
|
because of diminished cardiac output and blunted baro reflexes and decreased intravascular voume
|
|
|
pts with cushings have ...osis
|
hypokalemic, metabolic, alkalosis
|
|
|
...ventilation should be avoided with pts who have pheochromocytomoas
|
hypoventilation
|
|
|
histamine releasing drugs should be...in pheochromacytoma cases
|
avoided
|
|
|
what is the key to managmenet of pts with carcinoid syndrome
|
avoid anes. techniques that cause the tumor to release vasoactive substances
|
|
|
how much insulin to adults normally secrete
|
50 u
|
|
|
along with increase glucose into cells, insulin also causes an increase of ..into cells
|
potassium
|
|
|
lactic acidosis can be distinguished from DKA by a lactate level
|
above 6 mml/l
|
|
|
IN DM what is counterregulatory failure
|
inability to secrete epi and glucagon in response to hypoglycemia.
|
|
|
each milliliter of gl will raise BG by
|
2 mg/DL in 70 kg person
|
|
|
increased renin activity is associated with
|
secondary aldosternism
|
|
|
alkalosis will....ionized ca levels
|
lower
|
|
|
acidosis or hypoventilation will.....ionized ca levels
|
increase
|
|
|
a potentially suppersive dose of a steroid is about
|
5 mg prednisone for 2 weeks
|
|
|
to be avoided with pts who have carcinoid syndrome
|
tumor manipulation, catecholamines that may release further kallikrein , histamine releasing drugs, surgical manipulation,
|
|
|
mechanism of vasopressin release
|
Loss of intracellular water from osmoreceptors in the hypothalamus during dehydration → shrinkage of cells & release of ADH
|
|
|
growth hormone inhibitory hromone is called
|
somatostatn
|
|
|
with a decrease in bv of 15 to 25 percent, vasopressin secretion can increase
|
50 percent
|
|
|
% of t2/t4 that is protein bound
|
99
|
|
|
anti thyroid drug used for parturient
|
propylthiouracil
|
|
|
potassium iodide and propranalol is a good treatments for
|
hyper. before elective thyroidectomy
|
|
|
acetylcholine causes..insulin secretion
|
promote
|
|
|
volitiles cause..insulin secretion
|
inhibition
|
|
|
normal level of tsh is
|
0.4-5.0 mU/L
|
|
|
secondary hypoth is due to
|
hypothalmic or pituitary disease
|
|
|
labs for overt hypothyroidism
|
Marked ↓ T 4 & mean TSH of 90 mU/L
|
|
|
l thyroxine peaks in
|
6 to 12 hrs
|
|
|
Water soluble hormones dissolved in plasma & transported to target tissue via the interstitial space 2
|
peptide and catecholamines
|
|
|
Plasma protein bound such that less than 10% of hormone is free in solution; reservoir 2
|
steroid thyroid
|
