EDAIC Hepatic, Renal and Endocrine Anesthesia 5 — Questions and Answers
Question 1: A patient with Addison's disease presents for urgent bowel resection. They have not received their usual hydrocortisone today. What is the appropriate perioperative steroid management?
- Continue usual daily dose only; no supplementation needed
- Hydrocortisone 100 mg IV at induction, then 50 mg every 8 hours for 24-48 hours (Correct answer)
- Dexamethasone 8 mg IV at induction as single dose
- Methylprednisolone 1 mg/kg IV at induction only
Correct answer: Hydrocortisone 100 mg IV at induction, then 50 mg every 8 hours for 24-48 hours
Major surgery in primary adrenal insufficiency requires stress-dose steroid coverage: hydrocortisone 100 mg IV at induction then 50 mg q8h for 24-48h, tapering to maintenance as the patient recovers.
Question 2: In a patient with end-stage renal disease on hemodialysis, which neuromuscular blocking agent is SAFEST regarding accumulation of active metabolites?
- Vecuronium
- Rocuronium
- Cisatracurium (Correct answer)
- Pancuronium
Correct answer: Cisatracurium
Cisatracurium undergoes organ-independent Hofmann elimination, producing laudanosine (minimally active) without relying on renal or hepatic clearance, making it the safest NMBA in renal failure.
Question 3: Which of the following best describes the 'sick euthyroid syndrome' encountered in critically ill ICU patients and its anesthetic implication?
- Elevated TSH with low T4; thyroid replacement always required preoperatively
- Low T3 and T4 with normal or low TSH; routine replacement is not recommended (Correct answer)
- Elevated reverse T3 with high TSH; propylthiouracil should be given preoperatively
- Normal T3/T4 but elevated TSH; levothyroxine 0.5 mg IV should be given before anesthesia
Correct answer: Low T3 and T4 with normal or low TSH; routine replacement is not recommended
Sick euthyroid syndrome reflects reduced peripheral T4-to-T3 conversion in critical illness; TSH is normal or low, and thyroid replacement is generally not beneficial and may be harmful.
Question 4: During hepatic resection, the Pringle maneuver (portal triad occlusion) is applied for 45 minutes. What is the main anesthetic concern during reperfusion?
- Severe hypernatremia from glucose-containing flush solution
- Hemodynamic instability from release of vasoactive mediators and metabolic acidosis (Correct answer)
- Immediate coagulopathy from heparin rebound
- Rebound hypertension from catecholamine release
Correct answer: Hemodynamic instability from release of vasoactive mediators and metabolic acidosis
Reperfusion after prolonged Pringle maneuver releases accumulated lactic acid, potassium, and vasoactive mediators into the systemic circulation, causing hypotension, metabolic acidosis, and dysrhythmias.
Question 5: A 72-year-old with type 2 diabetes on metformin is scheduled for elective hip arthroplasty under spinal anesthesia. Metformin should be withheld preoperatively primarily to prevent:
- Perioperative hypoglycemia from potentiated insulin secretion
- Lactic acidosis if renal perfusion is compromised perioperatively (Correct answer)
- Interaction with neuraxial local anesthetics causing neurotoxicity
- Delayed emergence from residual biguanide CNS effects
Correct answer: Lactic acidosis if renal perfusion is compromised perioperatively
Metformin does not cause hypoglycemia but accumulates when renal perfusion is impaired (dehydration, contrast, hypotension), leading to lactic acidosis; it should be withheld 24-48h before procedures that risk renal compromise.
Question 6: A patient with TIPSS (transjugular intrahepatic portosystemic shunt) placement requires general anesthesia. What is a major hemodynamic concern unique to this patient?
- Severe portal hypertension requiring beta-blockade continuation intraoperatively
- Increased cardiac output and right heart volume overload due to shunt flow (Correct answer)
- Left-to-right cardiac shunt causing pulmonary hypertension
- Reduced splanchnic blood flow causing mesenteric ischemia under anesthesia
Correct answer: Increased cardiac output and right heart volume overload due to shunt flow
TIPSS creates a large portosystemic communication that increases venous return to the right heart, worsening the hyperdynamic circulatory state of cirrhosis and potentially precipitating right heart failure.
Question 7: In a patient with myxedema coma requiring emergency surgery, which of the following is the most critical anesthetic consideration?
- Risk of thyroid storm triggered by surgical stimulation
- Extreme sensitivity to all CNS depressants with risk of prolonged apnea and cardiovascular depression (Correct answer)
- Resistance to neuromuscular blockade requiring increased doses
- Hyperthermia risk requiring active cooling intraoperatively
Correct answer: Extreme sensitivity to all CNS depressants with risk of prolonged apnea and cardiovascular depression
Myxedema coma is associated with profound sensitivity to anesthetic agents, opioids, and sedatives due to reduced metabolic rate and impaired drug clearance, with high risk of cardiovascular collapse and prolonged apnea.
EDAIC Hepatic, Renal and Endocrine Anesthesia 5
A patient with Addison's disease presents for urgent bowel resection.
They have not received their usual hydrocortisone today.
What is the appropriate perioperative steroid management?