418 Final
what is a normal urine specific gravity?
1.005-1.030
what is a normal specific gravity?
1.010-1.025
what is a normal anion gap?
12-14
how long do we have to transplant a liver after procurement?
12-15hrs
how long do kidney transplant patients typically spend in ICU? total in the hospital?
12-24hrs 4-5 days
how long does a RBC live?
120 days
HHNS is a complication of what type of diabetes?
2
how many physicians must declare a patient brain dead before their organs can be procured?
2
ODS symptoms typically appear how long after rapid elevation of sodium?
2-6 days later
what is the T4:T3 ratio?
20:1
what is a normal bicarbonate/CO2?
23-29
what is a normal total CO2
23-30
when can cadaveric tissue donation take place?
24-48hrs after death
there is a ______% chance that siblings will be exact HLA matches
25; if identical twins, they WILL be exact matches
what is a normal serum osmolarity?
275-295
what IV fluid is used for SIADH?
3% saline (hypertonic)
what is the goal urine output for DKA fluid resuscitation?
30-60mL/hr
what is a normal urine osmolality?
300-1400
how high can blood sugars get with DKA?
300-800
what GCS score triggers the need to call LOPA?
5 or less
HLA matches of _______ are least likely to be rejected
5-6
how do you treat hypoglycemia for the patient with altered LOC?
50 ml of 50% dextrose IVP - given IV push in big bristajet if D50 not available - give glucagon 1mg SQ, IM, or IV follow with infusion of D5W or D10W to achieve a blood glucose >100
how fast should blood glucose drop with DKA treatment?
50-70mg/dL/hr
fluid intake is restricted to how much with SIADH?
500mL less than average daily UO
how high can blood sugars get with HHNS?
600-2000 (commonly over 1000)
how many HLA's are important for transplant and what are they?
6; A, B, and DR (1 of each from both mom and dad)
your patient has DI and weighs 70kg. their serum sodium is 160. what is their water deficit?
6L
when can graft vs host disease occur?
7-30 days after transplant
what is urine specific gravity changed to with DI?
<1.005
what is urine osmolality changed to with DI?
<200
what is serum osmolality changed to with SIADH?
<270
what A1C level is recommended?
<6.5
what is urine specific gravity changed to with SIADH?
>1.030
what UO is characteristic of DI?
>200mL/hr (2-20L/day)
what is serum osmolality changed to with DI?
>295
what are the typical serum osmolarity levels with HHNS?
>310
the anterior pituitary releases what 7 hormones?
ACTH TSH LH FSH PRL GH MSH
what are two endogenous causes of cushing syndrome?
ACTH-secreting pituitary tumor adrenal tumors/ectopic ACTH secreting tumors outside HPA axis
what is another name for vasopressin?
ADH
what are three potential problems with fluid replacement for HHNS/DKA?
CV overload, pulmonary edema, and cerebral edema
describe the bicarbonate buffer system
Carbon dioxide, a by-product of cellular respiration, is dissolved in the blood, where it is taken up by red blood cells and converted to carbonic acid by carbonic anhydrase. Most of the carbonic acid then dissociates to bicarbonate and hydrogen ions
your patient comes into the ER with DKA. you receive the following orders: regular insulin 0.15U/kg bolus now, then 0.1U/kg/hr insulin drip; NS 1,000mL/hr, K+ checks q2h, and bicarbonate 200mL/hr. which order do you implement first?
IV fluids!! NS 1,000mL/hr
what two scores are used for liver transplant urgency determination?
MELD (model for end-stage liver disease) or PELD (pediatric end-stage liver disease)
what can CAV lead to?
MI
DI is diagnosed based on what four things?
UO, serum Na, serum osmolality, and urine osmolality
what does a higher anion gap indicate?
acidosis
how do polyclonal antibodies work?
acts as lymphocyte immune globulin
what type of rejection has the most optimistic prognosis?
acute
describe the treatment for thyroiditis (6)
acute and subacute may resolve in weeks or months without treatment bacterial - antibiotics or surgical drainage NSAIDs can help with symptoms corticosteroids for severe pain propanolol or atenolol (beta blockers) for cardiovascular symptoms related to hyperthyroidism (HTN, palpitations, tachycardia) thyroid hormone replacement therapy for hypothyroid - usually need chronic replacement
what are 6 s/s heart transplant rejection?
SOB fever weight gain from fluid retention less urine production fatigue cardiac allograft vasculopathy
what are four parts of manging goiters?
TSH, T3 and T4 levels to determine if goiter is associated with hyper or hypothyroidism. thyroid antibodies to assess for thyroiditis surgical removal of large goiters - cause compresion of trachea and breathing problems treatment with thyroid hormone may prevent further enlargement
what act regulates organ/tissue donation?
anatomical gift act
what measurement do physicians use to determine whether they are accurately correcting acidosis with DKA?
anion gap
how do monoclonal antibodies work?
anti-antigen receptor antibody that interferes with the function of the T lymphocyte, the pivotal cell in the response to graft rejection
what are three treatments for psychogenic DI?
anti-compulsive meds anxiolytics H2O restriction
how can bacterial thyroiditis be treated? (2)
antibiotics or surgical drainage
what is a hyperacute graft rejection?
antibody mediated recipient already has antibodies against the donor organ, resulting in life-threatening reaction
what are 8 sympathetic responses to hypoglycemia?
anxiety tremors/nervousness cold/clammy skin tachycardia/palpitations hyperventilation n/v hunger diaphoresis
describe the goal of a subtotal thyroidectomy
approximately 90% of the thyroid tissue is removed - leave some of it so it will continue to produce T3 and T4 to have normal levels... doesn't always work, often overdo it and they end up having hypothyroidism
what drug class is cyclosporine in?
calcineurin inhibitor
what drug class is tacrolimus in?
calcineurin inhibitor
sirolimus is typically used in combination with what two drugs?
calcineurin inhibitor (tacrolimus, cyclosporine) and corticosteroids
what does triple immunosuppressant therapy consist of?
calcineurin inhibitor, corticosteroid, and mycophenolate mofetil
what are the most effective immunosuppressants?
calcineurin inhibitors
what type of immunosuppressants serve as the foundation for most regimens?
calcineurin inhibitors
what hormones regulate blood levels of calcium?
calcitonin and parathyroid
what is the treatment for hypocalcemia?
calcium gluconate
what is important to monitor after a patient has a subtotal thyroidectomy?
calcium/parathyroid levels
does hasimoto's onset fast or slow?
can be either fast or slow
how can alcohol consumption increase risk for hypoglycemia?
can inhibit liver's ability to make glucose, so don't have gluconeogenesis; drinking heavily without eating can block your liver from releasing stored glucose into your bloodstream, causing hypoglycemia.
how can phenothiazine cause DI?
can lead to sensation of dry mouth
what can myxedema coma result in?
cardiovascular collapse from hypoventilation, hyponatremia, hypoglycemia, and lactic acidosis.
what is trousseau sign?
carpopedal spasm -a spasmodic contraction of the muscles of the hands, feet, and especially the wrists and ankles (as that occurring in alkalosis and tetany) put blood pressure cuff around arm and leave it inflated for a few min, will see spasms of hands/fingers indicates hypocalcemia
what does the adrenal medulla secrete? (2)
catecholamines and peptides
the transplanted heart no longer responds to drugs like atropine and ephedrine. however, what drugs will the heart respond to?
catecholamines; extra sensitive to these
why can DKA cause electrolyte imbalances?
cations are lost with the anionic ketones to maintain electrical neutrality. ketones are negative ions, so positive cations are excreted with anions to maintain neutrality can have electrolyte problems from things like potassium following out into urine
long term survival of liver transplant depends on what?
cause of liver failure
what are three classifications of DI?
cental/neurogenic nephrogenic psychogenic
what are 18 s/s cushing syndrome?
central obesity buffalo hump on back of neck moon face acne poor wound healing purple striae hirsutism - hair where it shouldn't be hypertension weakness amenorrhea impotence headache polyuria & thirst labile moods frequent infections osteoporosis thin, fragile skin hyperglycemia
what can overzealous rehydration with DKA lead to?
cerebral edema
your patient has type 1 diabetes and comes to the ER complaining of a headache, slurred speech, anxiety, tremors, tachycardia, diaphoresis and nausea. what should you do first?
check their blood sugar
what is another name for hashimoto's?
chronic autoimmune thyroiditis
what is the treatment for hypothyroidism associated with thyroiditis?
chronic thyroid hormone replacement
what is hyperthyroidism?
clinical syndrome in which there is sustained release of thyroid hormones by the thyroid gland
what is tetany?
condition that is due usually to low blood calcium (hypocalcemia) and is characterized by severe spasms of the hands and feet, cramps, spasm of the voice box (larynx), and overactive neurological reflexes
how do you determine when DKA is resolved?
continue to check electrolytes, BUN, creatinine, and glucose q 2-4 hours until stable
what are the 6 treatment goals with DKA?
correct fluid/electrolyte balance monitor K+ and supplement dec serum glucose correct acidosis prevent further complications education
what is used for severe pain with thyroiditis?
corticosteroids
what hormones are deficient with secondary adrenocortical insufficiency?
corticosteroids and androgens are deficient but mineralocorticoids rarely are.
what is the most abundant glucocorticoid produced by the adrenal cortex?
cortisol
how can new onset T1DM precipitate DKA?
could be what brings them into ER or PCP initially
why should patients receiving steroids have frequent CBG checks?
could cause cushing syndrome which will increase blood sugar
what is hyperfunction of the adrenal cortex called?
cushing syndrome
why is most thyroid hormone unusable in the body?
it is bound to plasma proteins
how long does glucose remain attached to hemoglobin?
its entire lifespan (120 days)
ketone buildup with DKA results in what four s/s?
ketone breath (fruity) ketonuria (ketones in urine) kussmaul breathing (deep/labored; trying to compensate by blowing off CO2) nausea and vomiting
why does a higher anion gap indicate acidosis?
ketones are an anion and are not measured in electrolyte panel
what are 5 features of DKA?
ketosis acidosis hyperglycemia dehydration electrolyte imbalance
what are the 3 clinical features of DKA?
ketosis, acidosis, and hyperglycemia
what was the first organ to be successfully transplanted?
kidney
HLA matches are most important for what two transplants?
kidney and bone marrow
what 6 organs/tissues can be donated from a living donor?
kidney, bone marrow/stem cell, one or two lobes of liver, lung or part of a lung, part of a pancreas, part of the intestines
what are the three most commonly transplanted organs?
kidney, liver, and heart
what is hypothyroidism?
lack of circulating thyroid hormone
what should you expect regarding urine output after a kidney transplant and why?
large volumes of urine due to establishment of blood supply to new kidney
which kidney is preferred for transplant and why?
left; has longer renal vein
what will serum sodium be like with SIADH?
less than 134
which is more common, levothyroxine or liothyronine?
levo
what are two medications used to treat hypothyroidism?
levothyroxine and liothyronine
what organ is subject to a less aggressive immunologic attack after transplant?
liver
why is bleeding a complication of a liver transplant?
liver makes coagulation products
what four organs can be used in part for transplantation?
liver, lungs, pancreas, and intestines
what does chronic rejection usually result in?
lose the graft
how does chronic rejection manifest with liver transplants?
loss of bile ducts
why do we try to quickly get patients off of corticosteroids within a few years or avoid them entirely after organ transplant?
lots of side effects
how does TSH change with hyperthyroidism?
low
how is bicarbonate/CO2 affected by DKA?
low
how do calcium levels impact PTH secretion?
low calcium levels = inc secretion high = dec secretion
what triggers TSH release and what is it released by?
low circulating T3 and T4; pituitary gland
what causes electrolyte imbalance with DKA?
low pH --> potassium shifts from intra to extracellular in response to low pH... extra potassium is being excreted in urine (so may look normal), so once you finally treat acidosis, K+ will shift back into the cells, resulting in hypokalemia; sodium may look low as pull fluid from intracellular space and lose sodium in urine
what are the three treatments for nephrogenic DI?
low sodium diet <3g thiazide diuretic indomethacin
how are GI toxicities managed for patients taking mycophenolate mofetil?
lower dose or give smaller doses more frequently
with what organ is chronic rejection most common? where is is most rare?
lung liver
what method is used for the lung transplant waitlist?
lung allocation score
where are ectopic ACTH secreting tumors typically located? (2)
lung/pancreas
how does mycophenolate mofetil work?
lymphocyte specific inhibitor of purine synthesis suppressive effects on both T and B lymphocytes
how will WBC be affected by addison's disease?
lymphocytes increased (subtype of leukocytes)
why is it important to monitor calcium levels after thyroidectomy?
may accidentally remove or injure parathyroid gland, so can have crisis hypocalcemia!
patients severely affected with ODS may experience what?
may become "locked in"; they are awake but are unable to move or verbally communicate. they can usually move their eyes and blink
why is it important for the patient with exophthalmos to maintain eye moisture via saline drops, ointments, or even taping the eyes shut?
may not be able to close eyes which moistens the sclera, so will have dry sclera and risk for corneal abrasion
how can thyroid storm occur post-op?
may release some hormone with destruction of gland
why don't we measure bicarbonate regularly with labs?
measure serum total CO2 instead, which includes bicarb and other CO2 forms (dissolved and carbonic acid)
what is an acute rejection?
mediated by t-cytotoxic lymphocytes, activated against donor tissue
how do you treat cushing syndrome for patients that are not candidates for surgery?
medical adrenalectomy with drugs to suppress the synthesis and secretion of cortisol from the adrenal gland
what is gluconeogenesis?
metabolic pathway in the liver that results in the generation of glucose from non-carbohydrate carbon substrates such as lactate, glycerol, and glucogenic amino acids
T3 and T4 regulate what 6 things?
metabolic rate caloric requirements oxygen consumption carb/lipid metabolism growth/development brain function
what are four causes of psychogenic DI?
middle-aged women psychiatric illness phenothiazine structural lesion in thirst center
PRL has what 6 functions?
milk production immune system maintenance puberty ovulation libido fertility
what is the treatment for subclinical hyperthyroidism?
monitor and recheck
how long does it take for chronic rejection to occur?
months to years
describe the relationship between bicarb and CO2 lab values
most of the CO2 in serum is in the form of a substance called bicarbonate (HCO3-). Therefore, the CO2 blood test is really a measure of your blood bicarbonate level; if CO2 is low, their bicarb is prolly low!
what are 13 s/s hypocalcemia?
muscle aches/cramps tingling, burning, or numbness in fingertips, toes, and lips muscle spasms, esp around the mouth dysphagia voice changes wheezing/bronchospasm patchy hair loss dry skin brittle nails fatigue anxiety/depression trousseau sign chvostek's sign
why does hypocalcemia result in muscle aches and spasms?
need calcium for normal muscle contraction
describe the procedure for an open live donor kidney procurement
nephrectomy performed by a urologist or transplant surgeon begins an hour or two before the recipient's surgery is started rib may need to be removed for adequate view takes about 3 hours if open
what three things cause central/neurogenic DI?
neurosurgery, traumatic brain injury, tumors
your patient is recovering from a heart transplant and is on tacrolimus, mycophenolate mofetil, and a corticosteroid. they begin to complain of a HA, paresthesia, and tremors. what do you suspect?
neurotoxicity from tacrolimus, a calcineurin inhibitor
what is graft vs host disease?
newly transplanted donor's cells attack the recipient's body
what is the treatment for chronic rejection?
no definitive therapy; primarily supportive
what are 3 types of goiters?
nontoxic nodular toxic nodular
what two catecholamines are released by the adrenal medulla?
norepinephrine and epinephrine
how is sodium affected by DKA?
normal or low
how is K+ affected by DKA?
normal, low, or elevated
describe the pathophysiology of DI
normally, when serum osmolality rises above 290mOsm/kg H2O, the synthesis and release of ADH is triggered. In DI, no ADH is released and the kidney is incapable of concentrating urine and retaining water.
what is psychogenic DI?
not really ADH problem, but patient drinks too much; compulsive drinking >5L/day
what is cardiac allograft vasculopathy (CAV)?
o accelerated coronary artery disease-like process characterized by vascular injury induced by a variety of noxious stimuli, including the immune system response to the allograft, ischemia-reperfusion injury, viral infection, immunosuppressive drugs, and classic risk factors such as hyperlipidemia, insulin resistance, and hypertension
what are 3 risk factors for hypoglycemic unawareness?
older patient frequent episodes of hypoglycemia beta blockers
where is the adrenal gland located?
on top of the kidneys
even with the large number of people signed up as organ donors, why is there still a severe organ shortage?
only 3/1,000 people die in a way that allows for solid organ donation
describe chronic rejection
organ is infiltrated with t and b cells characteristic of chronic, low-grade immune-mediated injury; results in fibrosis and scarring
why is geographic location important to consider when matching an organ donor to a recipient?
organ must get to recipient in specific window of time
what does rapid sodium correction result in?
osmotic demyelination syndrome
your patient is receiving hypertonic saline for SIADH treatment. their sodium level pre-treatment was 128. 8 hours after starting treatment, their sodium levels increased to 140. after 24 hours, their serum sodium was 150. after 48 hours, the patient begins to exhibit dysarthria, dysphagia, confusion, lethargy, and difficulty moving. what do you suspect?
osmotic demyelination syndrome
why are people with cushing syndrome at risk for fractures?
osteoporosis
what is diabetes insipidus characterized by?
output of vast quantities of very dilute urine and increased serum osmolality due to dehydration (1-2L of urine/hr that's very clear)
what are four causes of goiters?
overactive thyroid lack of iodine in diet certain drugs certain foods
the posterior pituitary releases what two hormones?
oxytocin vasopressin (ADH)
describe bicarbonate dosing for DKA
pH < 6.9 - NAHCO3 (100 mmol in 400ml) and infuse at 200 ml / hr ) pH 6.9 - 7.0 - NAHCO3 (50 mmol in 200ml and infuse at 200 ml / hr ) pH of 7.0 - no NAHCO3
what are five s/s thyroiditis?
pain localized in thyroid or radiating to throat, ears, or jaw fever chills sweats fatigue
what releases parathyroid hormone?
parathyroid glands
what is the anatomical gift act?
passed in the US in 1968 and has since been revised in 1987 and in 2006; sets a regulatory framework for the donation of organs, tissues, and other human body parts in the US.; helps regulate body donations to science, medicine, and education; HCPs required to report all deaths to organ procurement agency
what is an autologous stem cell transplant?
patients receive their own stem cells back after myeloablative chemotherapy. use when there is no suitable allogenic donor or to avoid problems of rejection or graft vs host disease
a subtotal thyroidectomy is indicated in what three cases?
patients unresponsive to anti-thyroid therapy patients with large goiters thyroid cancer
what is Hgb A1C?
percentage of hemoglobin with glucose attached to it
which cells are more mature, bone marrow stem cells or peripheral stem cells?
peripheral
what is thyrotoxicosis?
physiologic effects of hyper metabolism from excesses of circulating T3 or T4
what does oxytocin do? (2)
plays a crucial role in the childbirth process and also helps with male reproduction
thyroid storm/thyrotoxicosis commonly occurs in what two cases?
post-op thyroidectomy or chronic hyperthyroidism
how do calcineurin inhibitors work?
prevent cell-mediated attack against transplanted organ
after organ transplant, what is the goal of immunosuppressants?
prevent rejection while maintaining sufficient immunity to prevent overwhelming infections
what is the difference between primary and secondary adrenocortical insufficiency?
primary is a problem with the adrenal gland itself; secondary is a lack of pituitary ACTH secretion
what is another name for psychogenic DI?
primary polydipsia
how will TSH, T3, and T4 be affected by primary hypothyroidism? secondary?
primary: high TSH, low T3 and T4 secondary: all low
where is ADH produced and stored?
produced in the hypothalamus and stored in the posterior pituitary
what does diabetic ketoacidosis result from?
profound deficiency in insulin
what is myxedema coma?
progression of the mental sluggishness, drowsiness, and lethargy of hypothyroidism to notable impairment of consciousness or coma.
what is PRL?
prolactin; hormone secreted by the pituitary gland that stimulates lactation (milk production)
what is the purpose of androgens? (3)
promote growth spurt in adolescence, secondary sex characteristics, and libido in both sexes
extrapontine involvement of ODS can have what five s/s?
psychiatric disturbances, catatonia, postural limb tremor, myoclonic jerks, and a parkinsonian picture with choreoathetosis or dystonia that responds to dopaminergic treatment
how often should sodium levels be assessed with SIADH treatment?
q4h
what is primary hypothyroidism? secondary?
r/t destruction of tissue, so problem in thyroid itself have high TSH pituitary disease with low TSH (usually)... tumors, disease processes, etc
what three things indicate an acute phase of addison's disease, AKA addisonian crisis?
rapid worsening of chronic symptoms fever LOC changes
should fluids be replaced rapidly or slowly for DI?
rapidly
what determines whether CNS or SNS symptoms predominate with hypoglycemia? (2)
rate of onset and patient's age
what is the treatment for thyroid storm?
reduce circulating thyroid hormone with PTU, methimazole; treat fever, replace fluids, beta blockers, etc
describe typical insulin dosing for DKA
regular insulin @0.15 units/kg bolus, then....0.1 unit/ kg /h by infusion - will have sliding scale to follow with q1h ABGs if serum glucose doesn't fall by 50 - 70 mg/dL in one hour double the infusion the insulin infusion rate should be doubled every hour until a steady decline in serum glucose of this magnitude is achieved. when serum glucose reaches 200- 250mg/dl add dextrose to saline solution
what does aldosterone do?
regulates sodium and potassium to maintain ECF volume
how does pH change with HHNS?
relatively normal unless in shock with lactic acidosis from dehydration
what is the only treatment for hyperacute rejection?
removal of the graft
sirolimus is typically given for what type of organ transplants?
renal
what three things cause nephrogenic DI?
renal disease, genetic predisposition, or lithium
what does aldosterone act on and how?
renal tubules of the kidney; tells it to reabsorb sodium and excrete potassium/hydrogen
what are the two means of treating addison's disease?
replace gluco/mineralocorticoids IV solu-cortef with D5
how is potassium corrected with addison's disease?
replace mineralocorticoids to manage fluid/electrolyte balance
what does the anatomical gift act require HCPs to do?
report all deaths (or predicted deaths) to organ procurement agency
what is the goal of hypothyroidism treatment?
restoration of a euthyroid state with hormone replacement therapy
what causes weight gain with SIADH?
retaining fluid
what causes HTN with cushing syndrome?
retaining of sodium
what food is a good source of iodine?
seafood
is TSH deficiency a primary or secondary cause of hypothyroidism?
secondary
how do primary and secondary adrenocortical insufficiency present differently?
secondary does not have hyperpigmentation
what is a nodular goiter?
secrete thyroid hormone independent of TSH (not stimulated by TSH, just release on their own) usually benign follicular adenomas
HHNS most often occurs in type 2 diabetics with what characteristics?
sick elderly with comorbidities
describe how HHNS is different from DKA
similar to DKA in that they have high blood sugar, osmotic diuresis, and dehydration... difference is no ketoacidosis/metabolic acidosis unless it's lactic acidosis from dehydration
what are three target organs of graft vs host disease?
skin, liver, GI tract
is symptom onset fast or slow with HHNS?
slow
what can we do to prevent ODS with SIADH treatment?
slow and steady sodium replacement
how does the heart's response to hemodynamic changes differ after transplant and why?
slower due to dennervation of sympathetic and parasympathetic nervous systems
do we want to decrease blood sugar quickly or slowly with HHNS?
slowly
should sodium be replaced quickly or slowly with SIADH?
slowly
when is ADH primarily released? (1) when is it secondarily released? (2)
small increases in serum osmolality hypovolemia and hypotension
how do we correct acidosis for DKA?
sodium bicarb IV
what medication is used via IV inpatient for addison's disease?
solu-cortef
what two peptides are released by the adrenal medulla?
somatostatin and substance P
the high blood sugar levels of HHNS can lead to what 5 neuro manifestations?
somnolence, coma, seizures, hemipariesis and aphasia
what is chvostek's sign?
spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland; seen in tetany with hypocalcemia
what is cushing syndrome?
spectrum of clinical abnormalities caused by excess corticosteroids, particularly the glucocorticoids
in patients with pontine involvement of ODS, what s/s occur early on?
speech abnormalities occur early and persist, and patients often become mute
what is DKA?
state of intracellular dehydration that results from elevated blood sugar and osmolality, causing diuresis and ketone production, resulting in acidosis
graft vs host disease is commonly associated with what type of transplant?
stem cell
what is an allogenic stem cell transplant?
stem cells are acquired from a donor who, through HLA tissue typing, has been determined to be HLS matched to the recipient
what is a peripheral stem cell transplant?
stem cells taken from the blood stream and reinfused into recipient; these stem cells are more mature
what is a bone marrow transplant?
stem cells taken from the bone marrow and injected into recipient bone marrow
how does indomethacin work for nephrogenic DI?
steroid that increases renal responsiveness to ADH
addisonian crisis is triggered by what four things?
stress sudden withdrawal of corticosteroid hormones adrenal surgery sudden pituitary gland destruction
what 6 things increase cortisol levels?
stress, burns, infection, fever, acute anxiety, and hypoglycemia
what are two types of thyroiditis?
subacute granulomatous thyroiditis acute thyroiditis
what are goitrogens?
substances (whether in drugs, chemicals, or foods) that disrupt the production of thyroid hormones by interfering with iodine uptake in the thyroid gland
does DKA onset suddenly or gradually?
suddenly (within hours)
how can hypoglycemia lead to a coma?
sugar drops too low and brain needs glucose to function, so goes into coma
how is myxedema coma treated? (2)
support of vital functions IV thyroid hormone replacement
what is a xenograft?
surgical graft of tissue from one species to an unlike species (or genus or family). a graft from a baboon to a human is a xenograft
how do you treat cushing syndrome caused by an adrenal tumor?
surgical removal of adrenals; need long-term replacement of hormones
what is the etiology of hyperthyroidism?
sustained increase synthesis and release of thyroid hormone
what hypoglycemia symptom is typically not blocked by beta blockers?
sweating
how will rapid onset hypoglycemia present? slow onset?
sympathetic response like sweating and shaking will predominate CNS symptoms like neuro changes predominate
why do blood sugars get so high before symptoms are recognized with HHNS?
symptom onset is slow
what is treatment for hyperthyrodism based on?
symptoms
describe the pathophysiology of hypoglycemia
symptoms are related to insufficient levels of glucose for the brain (altered LOC) and catecholamine effects
what is SIADH?
syndrome of inappropriate antidiuretic hormone; over secretion of ADH
what is liothyronine?
synthetic T3
what is levothyroxine?
synthetic T4
what are two examples of calcineurin inhibitors?
tacrolimus and cyclosporine
what are 6 s/s thyroid storm?
temp up to 105.3, restlessness, agitation, seizures, delirium, coma
what makes a lung transplant successful?
the ability to wean the patient off the vent
what is myxedema and when does it occur?
the accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues may occur with severe longstanding hypothyroidism
describe the pathophysiology of DKA
the deficit of insulin causes the inability of glucose to move into the cell increasing serum glucose levels gluconeogenesis and glycogenolysis occur in the liver further increasing hyperglycemia (in response to cells starving for glucose) elevated serum glucose leads to increased intravascular osmotic pressure which draws fluid from intracellular space >>kidneys excrete glucose, ketones and water (osmotic diuresis)>>loss of electrolytes and dehydration to compensate: renin- angiotensin-aldosterone and ADH are active>>decrease in urine output and increased BP (become dehydrated) finally, compensatory mechanisms are exhausted leading to cardiovascular collapse from severe dehydration; can go into diabetic coma a breakdown of fatty acids leads to a buildup of ketones decreasing the pH (as low as 7.2)
cardiac allograft vasculopathy is induced by what 5 things?
the immune system response to the allograft, ischemia-reperfusion injury, viral infection, immunosuppressive drugs, and classic risk factors such as hyperlipidemia, insulin resistance, and hypertension
what is the bicaval approach to heart transplant?
the right atrium of the recipient's heart (with SA node and maintenance of atrial conduction) is preserved, and then donor heart is connected - results in 2 P waves
why don't atropine and ephedrine work for patients with heart transplants?
these drugs act on the vagolytic mechanism, which no longer directly innervates the heart
why is it important to monitor renal function with calcineurin inhibitors?
they are nephrotoxic
why are patients at high risk for infection following organ transplant?
they are on immunosuppresants to prevent rejection
what is TSH?
thyroid stimulating hormone; stimulates thyroid to release T3 and T4
what is another name for thyrotoxicosis?
thyroid storm
what is an allograft?
tissue graft from a donor of the same species as the recipient but not genetically identical
why do we give beta blockers for graves disease?
to relieve symptoms
how do you treat cushing syndrome caused by a pituitary tumor?
trans sphenoidal resection of tumor; go in through nose and suck it out
what are two other names for CAV?
transplant coronary artery disease or cardiac transplant vasculopathy
what is the target of treatment for cushing syndrome?
treat the cause
with stem cell transplants, many patients die from what two things?
treatment-related complications or from recurrence of the original disease
true or false? ODS is irreversible most of the time
true
true or false? acute rejection reactions are common with organ transplantation
true
true or false? for cadaver donors with a perfect recipient match, one kidney MUST be sent to that recipient regardless of where they are geographically or on waiting list
true
true or false? laparoscopic nephrectomies are the primary method of live donor kidney procurement
true
true or false? little can be done to modify the course of graft vs host disease
true
true or false? living organ donors are usually family members of the recipient
true
true or false? most thyroid nodules are benign
true
true or false? the liver can be transplanted from a live donor
true
true or false? thyroid storm is a life threatening emergency
true
true or false? graft vs host disease can occur with blood products
true, if product contains lymphocytes
true or false? if the patient is signed up as an organ donor, LOPA does not need consent from the family before procuring the organs
true, technically... but they usually approach the family anyway to explain everything
true or false? for a heart-lung transplant, there is a better chance that something will become available versus an individual heart or lung transplant
true; maintained on both waitlists, and if one becomes available, the other comes with it
true or false? there is no adequate treatment for graft vs host disease
true; steroids are used, but increase risk for infection
what is central obesity?
truncal obesity with skinny arms and legs
deficient growth hormone will have what 6 s/s?
truncal obesity, decreased muscle mass and strength, weakness, fatigue, depression, flat affect.
how do you treat cushing syndrome caused by an ectopic ACTH secreting tumor?
tumor resection
what are 7 causes of hypopituitarism?
tumors, lymphoma, metastases, infections (TB, syphilis), postsurgical resection, TBI, radiation of brain
besides bone marrow and the bloodstream, where can stem cells be acquired?
umbilical cord blood
what are 8 s/s of lung transplant rejection?
unable to extubate flu-like symptoms cough/chest pain fatigue fever shortness of breath decreased incentive spirometry decreased oxygen saturation
how is addisonian crisis treated?
unresponsive to usual treatment for circulatory collapse... fluids and vasopressors won't work! need corticosteroid replacement
how quickly should sodium levels increase with treatment for SIADH?
up to 12 in first 24hrs with total rise of 18 in 48hrs
with DKA, where can ketones be found?
urine and serum
what is the anion gap measurement?
usually for every cation, we have a balancing anion, so should be equal; don't measure all the anions in the serum, so we call that the anion gap and there's a certain amount that is normal; just know that physicians use this to determine if they're correcting the acidosis
where is the transplanted kidney placed and how is it connected?
usually placed extra-peritoneally in the iliac fossa and connected to internal iliac artery and vein
what do desmopressin, vasopressin, and lypressin do?
vasoconstrict
what does preparation for a stem cell transplant consist of?
very high doses of chemotherapy with or without radiation therapy to kill off existing bone marrow
wha causes subacute granulomatous thyroiditis?
viral infection
ADH is released in response to what three things?
volume depletion, increased serum osmolality (dehydration), and hypotension
what are three treatments for HHNS?
volume resuscitation, electrolyte correction, and insulin to get sugar down
what is the difference between cadaveric donation and brain death/cardiac death donation?
we are more limited with what we can obtain from cadavers... we can only get certain tissues and organs, not so much solid organs. with brain death or DCD, can get solid organs
deficient ACTH will have what 7 s/s?
weakness, fatigue, headache, dry and pale skin, diminished axillary and pubic hair, lowered resistance to infection, fasting hypoglycemia (cortisol deficiency)
how do you treat cushing syndrome caused by high doses of steroids?
wean them down or stop if possible
after how long can acute and subacute thyroiditis resolve on its own?
weeks or months
what are 5 s/s SIADH?
weight gain lethargy anorexia n/v severe neuro changes with sodium <120
what is hypoglycemic unawareness?
when a person does not experience the warning signs and symptoms of hypoglycemia until the glucose levels reach a critical point (like a coma)
what does parathyroid hormone do?
when calcium levels are low, this triggers pulling of calcium from bone stimulates transfer of calcium from bone to blood inhibits bone formation triggers calcium reabsorption and phosphate excretion in the kidney activates vitamin D
when do severe neuro changes occur with SIADH?
when sodium drops below 120
when are benign thyroid nodules dangerous?
when they cause tracheal compression
when is mycophenolate mofetil most effective?
when used in conjunction with tacrolimus or cyclosporine
what should you first determine when deciding how to treat hypoglycemia?
whether they are conscious or not
what is the difference between brain death donors and cardiac death donors?
with brain death, all support is left on the patient so organs can perfuse during the procedure and they are kept "alive" with DCD, support is withdrawn and expect pt to pass within an hour
with DKA, what do we do to correct hyperkalemia?
with insulin therapy, potassium will be driven back into cells
how quickly does an acute rejection occur?
within days to months
how quickly does hyperacute rejection occur?
within minutes to hours
deficiency of FSH and LH will have what 3 s/s in women? what 6 s/s in men?
women: menstrual irregularities, loss of libido, changes in secondary sex characteristics such as decreased breast size men: testicular atrophy, diminished spermatogenesis, loss of libido, impotence, decreased facial hair and muscle mass
describe how graft vs host disease affects the skin, liver, and GI tract
· Skin painful pruritic rash starting with hands and feet. Can become generalized. · Liver - mild jaundice with elevated liver enzymes to hepatic coma · GI - mild to severe diarrhea, severe abdominal pain, GI bleeding, and malabsorption
the parkinsonian symptoms that can occur with ODS can be treated with what?
dopaminergic treatment
what are 13 s/s DKA?
dry mouth polyuria polydipsia polyphagia n/v abd pain dehydration dry skin flushed hypotension tachycardia acetone breath mental confusion/LOC changes
what can exophthalmos result in?(5)
dry/irritated corneal surface ulcers loss of vision muscle weakness diplopia
describe the s/s myxedema (6)
dull, puffy skin coarse, sparse hair peri-orbital edema prominent tongue mask-like effect dec CO/contractility - HF
what are 11 s/s ODS?
dysarthria, dysphagia, paraparesis or quadriparesis, behavioral disturbances, movement disorders, seizures, lethargy, confusion, disorientation, obtundation, and coma
when should levothyroxine be scheduled and why?
early morning before breakfast; food will inhibit absorption, so take on empty stomach
decribe typical potassium dosing for DKA
if K+ < 3.3 mEq/L, hold insulin and give 40 mEq K+ per hour (insulin drives K+ into cells, so need to correct first so we don't drop it even more) if K+> 5.0 do not give K+ but check levels q 2 hours (as you correct the acidosis, will drop) if K+ is between these values, give 20 -30 mEq K+ in each liter of fluid.
what IV fluids should you use for DKA based on the client's BP?
if high or normal switch to 0.45% saline. If low, continue with 0.9% saline.
what makes thyroid hormone biologically active?
if it is free - not bound to plasma protein
when would a goiter need to be surgically removed?
if obstructing trachea and causing breathing problems
describe the process for DCD
if patient is expected to pass within an hour of withdrawing life support, will take them down to the OR, withdraw support, then wait to see if they die within a certain amount of time... if they do, then organs can be procured
how can insulin pumps lead to DKA?
if they malfunction, battery dies, needle disconnects, etc
what drug class is sirolimus in?
immunosuppresant
what is the treatment for acute rejection?
immunosuppressants
what causes exophthalmos with hyperthyroidism?
impaired venous return, causing edema and swelling and inc fat deposits in orbital tissue/ocular muscles
why do breathing patterns differ between DKA and HHNS?
in DKA< have kussmaul since trying to blow off CO2; in HHNS, have shallow breathing
how does growth hormone deficiency present differently in adults vs children?
in adults, findings are subtle and nonspecific, while in children we will see changes in growth and development
where is the thyroid gland located?
in the neck
what does LH do in women? men?
in women, LH helps regulate the menstrual cycle and egg production in men, LH stimulates the production of testosterone, which plays a role in sperm production.
what are 6 severe neuro changes that take place when serum sodium drops below 120 from SIADH?
inability to concentrate, confusion, seizures, decreased LOC, coma, death
what is central/neurogenic DI?
inability to secrete an adequate amount of ADH
describe the pathophysiology of SIADH
inc ADH release leads to inc water reabsorption, inc intravascular volume, and dilutional hyponatrema/dec serum osmolality
what can the dehydration of DKA lead to?
inc Bun/Creatinine (become prerenal and can have intrarenal AKI if not treated)
what causes the bruit with hyperthyroidism?
inc vascularity of thyroid
how will ESR be affected by addison's disease?
increased
how will WBC be affected by cushing syndrome?
increased
how will glucose be affected by cushing syndrome?
increased
how will potassium be affected by addison's disease?
increased
how will sodium be affected by cushing syndrome?
increased
what is urine osmolality changed to with SIADH?
increased
how is serum osmolality affected by DKA?
increased >290
what causes hyperpigmentation of the skin with addison's disease?
increased secretion of β-lipotropin (which contains melanocyte-stimulating hormone.); pituitary still works and is secreting ACTH which causes this
how does epinephrine affect glucose metabolism?
increases glucose production by stimulating both glycogenolysis and gluconeogenesis from amino acids, glycerol, and pyruvate. increases the delivery of these gluconeogenic substrates from the peripheral tissue, inhibits glucose utilization by several tissues, and, via the alpha-2-receptors, inhibits insulin secretion
what are polyclonal antibodies used for after organ transplant? (2)
induction therapy (to initially suppress them) or to treat acute rejection.
what is the biggest problem with graft vs host disease?
infection
myxedema coma is precipitated by what four things?
infection drugs exposure to cold trauma
what are two risks of stem cell transplants?
infection and bleeding dyscrasias
thyroid storm can be triggered by what three things?
infection, trauma (surgery), or stressors
what are 9 precipitating factors for HHNS?
infection/sepsis/illness diet controlled DM (not on insulin but need it) pancreatitis trauma severe diarrhea severe burns peritoneal dialysis MI hypertonic feedings
immunosuppressants put patients at risk for what two things?
infections and malignancies/cancers
what are four adverse reactions to calcineurin inhibitors?
infections, malignancy, nephrotoxicity, neurotoxicity
what is urine output changed to with DI?
1-1.5L/hr
true or false? patients with recurring infections like viral hepatitis are not candidates for liver transplant
false; still a candidate, but infection may recur
does thyroiditis onset fast or slow?
fast
deficiency of TSH will have what 5 s/s?
fatigue, cold intolerance, constipation, lethargy, weight gain (mild hypothyroidism)
what are the s/s hypothyroidism? (7)
fatigue/lethargy slowed memory low exercise tolerance constipation cold intolerance hair loss thin, coarse hair
describe what you must be prepared to do when calling LOPA about your patient
have chart nearby to provide info about patient and document referral number in chart and give to nursing supervisor
what is the most common cause of cushing syndrome?
iatrogenic administration of exogenous corticosteroids (prednisone, hydrocortisone, dexamethasone)
why does HHNS not have ketoacidosis like DKA even though they both occur as a result of high blood sugar?
HHNS occurs in type 2 diabetics, and type 2 usually make SOME insulin, enough to prevent fatty acid breakdown and production of ketones
is the mortality rate higher with DKA or HHNS? why?
HHNS; probably since it targets the sick elderly specifically while DKA targets young population as well
what thyroid hormone is produced the most?
T4
what is the difference between T3 and T4?
T4 has a longer half life, but T3 is 3-4x stronger
describe the volume replacement regimen for DI treatment (formula)
(0.6 [kg weight]) X (Serum Sodium-140) = 140
DKA usually occurs with what type of diabetes?
1
what is a normal urine output per day?
1-1.5L
how long do we have once the heart is procured to transplant it without extra preservation means?
4-6hrs
how much time do we have to transplant lungs after procurement without extra technology?
4-6hrs
what 5 aspects go into matching donors with recipients?
ABO group HLA geographic location body size severity of condition of recipient
what kind of IV fluid is solu-cortef mixed with?
D5 solution
what drug is used most often for central DI?
DDAVP/desmopressin
high anion gaps are caused by what 3 abnormal things? what are 3 normal causes?
DKA, lactic acidosis, and uremia diarrhea, hypokalemia, renal tubular acidosis
what is mycophenolate mofetil limited by?
GI toxicities (NVD)
what organization regulates tissue and organ transplants in louisiana?
LOPA
what five electrolytes are lost in the urine with HHNS?
Na, K, Mg, Ca, Ph
which is better for an acute hyperthyroidism crisis, PTU or methimazole? what about for chronic management?
PTU methimazole
what are four treatments for graves disease?
PTU methimazole iodine beta blockers
what 6 drugs are goitrogens?
PTU (propylthiouracil) tapazole sulfonamides salicylates lithium amiodarone
what two drugs inhibit the release of T3 and T4?
PTU and tapazole
what's the difference between PTU and methimazole?
PTU is more effective and works faster in a crisis, but TID dosing so less convenient; methimazole is once a day and better for chronic management
what 3 hormones are released by the thyroid?
T3, T4, and calcitonin
what is graves disease?
autoimmune disorder of unknown cause that causes development of antibodies to TSH receptors
what can cause hypoglycemic unawareness?
autonomic neuropathy
what are six contraindications to organ transplantation?
disseminated malignancies (cancer with metastasis), refractory or untreated cardiac disease, chronic respiratory failure, extensive vascular disease, chronic infection, and unresolved psychosocial disorders
what is osmotic demyelination syndrome?
a degenerative process that erodes away the myelin sheath that normally protects nerve fibers. demyelination exposes these fibers and appears to cause problems in nerve impulse conduction that may affect many physical systems.
thyroiditis frequently causes what?
a goiter
where may pain be experienced with addisonian crisis? (3)
abdomen, lower back, or legs
what makes a kidney transplant successful?
ability of kidneys to concentrate urine
what makes a heart transplant successful?
ability to maintain hemodynamic stability without drugs like epinephrine
what is hypoglycemia?
abnormally low blood glucose level (<70mg/dl)
what serum sodium is characteristic of DI?
above 145
what serum osmolality is characteristic of DI?
above 295
how does chronic rejection manifest with heart transplants?
accelerated coronary artery disease
what is primary adrenocortical insufficiency called?
addison's disease
what is acute adrenocortical insufficiency called?
addisonian crisis
what is nephrogenic DI?
adequate ADH but the inability of the nephrons to respond to ADH.
what is hypofunction of the adrenal cortex called?
adrenocortical insufficiency
what is ACTH?
adrenocorticotropic hormone; stimulates adrenal gland
what is the most abundant mineralocorticoid released by the adrenal cortex?
aldosterone
what causes ketone production in DKA?
all cells except brain cells need insulin to use glucose, so if not brought in by insulin, begins to break down fat and results in byproduct ketones in blood, which are acids and cause metabolic acidosis
what are three types of stem cell transplants?
allogenic syngeneic autologous
what is a syngeneic stem cell transplant?
allogenic from one identical twin to the other
what antiarrhythmic can cause thyroid problems such as goiters?
amiodarone
where do muscle spasms especially occur with hypocalcemia?
around the mouth
why may patients with hashimoto's have a transient phase of hyperthyroidism before they become hypothyroid?
as antibodies destroy thyroid tissue, may leak thyroid hormone
why is it important to monitor K+ and supplement as needed for DKA treatment?
as we correct acidosis, potassium will shift back into cells and will drop, so need to monitor and adjust frequently
the risk for ________ increases as LOC changes with drops in sodium from SIADH
aspiration
swallowing dysfunction from ODS can lead to what?
aspiration pneumonia and respiratory failure
what IV fluids are used for DKA?
at first, NS for low BP or 0.45% saline for high/normal BP, then when glucose gets to 250 will switch to D5 1/2NS...
what is the usual cause of addison's disease?
autoimmune adrenalitis, destroying the adrenal cortex and causing a loss of hormones
what causes acute thyroiditis?
bacterial/fungal infection
what urine osmolality is characteristic of DI?
below 100, with SG <1.005
what is urine output changed to with SIADH?
below normal
what may high PRL (hyperprolactinemia) be caused by?
benign tumor in the pituitary gland called a prolactinoma
what medications will mask s/s hypoglycemia?
beta blockers like propanolol and atenolol
what is used for cardiovascular symptoms of thyroiditis related to hyperthyroidism?
beta blockers like propanolol or atenolol
what are two advantages of kidney transplants from live donors?
better graft survival rate elective surgery, so can find the best match and schedule it when they are in good health
what are the two approaches to heart transplants?
biatrial and bicaval
what comprises most of the body's CO2 content?
bicarb
what heart transplant approach results in 2 P waves and why?
bicaval; right atrium of the recipient's heart (with SA node and maintenance of atrial conduction) is preserved
what are 3 complications post-op liver transplant?
bleeding, infection, and rejection
how do PTU and methimazole work?
block the synthesis of thyroid hormones.
how do beta blockers increase risk for hypoglycemia?
blocks sympathetic response, which helps manage hypoglycemia... may not recognize symptoms of hypoglycemia
how is bicarb measured with ABGs?
blood gas machine measures pH and pCO2 and then calculates a bicarbonate value using the Henderson-Hasselbalch equation
how do you treat hypoglycemia for the conscious patient?
blood glucose < 70 15 -20 g simple sugar (orange juice, candy, honey, etc) blood glucose < 50 20-30 g simple sugar recheck blood glucose 15 -20 minutes and repeat sugar as needed keep precipitating factors in mind since insulin will keep working and could have another drop... may need to put on drip of D10W until insulin wears off and do frequent CBG checks 4oz sweetened CHO beverage, unsweetened fruit juice, 1 tbsp honey, pieces hard candy, etc.
do goiters occur with hyperthyroidism, hypothyroidism, or both?
both
what are the four types of organ donors?
brain death donation after cardiac death cadaver donor (after death) living donor
what are stem cells?
brand new cells that have not differentiated
what is a corticobulbar sign of ODS?
brisk jaw jerk
what are 9 foods that are goitrogens?
broccoli brussel sprouts cabbage cauliflower kale mustard peanuts strawberries turnips
how does chronic rejection manifest with lung transplants?
bronchiolitis obliterans
what is exophthalmos?
bulging of the eyes
true or false? after kidney transplant, patients put out a lot of urine since they've been retaining fluids before the transplant, so it is important to continue to restrict fluids in order to promote this diuresis process
false; need to replace fluids as they are lost or else they could become prerenal and have ATN
what is the biatrial heart transplant approach?
damaged heart removed at midatrial level and donor heart connected at the left atrium, pulmonary artery, aorta, & right atrium
what are 9 CNS s/s of hypoglycemia?
dec ability to reason/remember changing mental status emotional lability HA dizziness slurred speech loss of coordination/proprioception numbness coma
how do thiazide diuretics work for nephrogenic DI?
dec flow to ADH-sensitive distal nephrons, which encourages salt and water reuptake
how will glucose be affected by addison's disease?
decreased
how will potassim be affected by cushing syndrome?
decreased
how will sodium be affected by addison's disease?
decreased
how will plasma cortisol be affected by addison's disease?
decreased <5 at 0800
what is kussmaul breathing and why is it present with DKA?
deep/labored; trying to compensate for acidosis by blowing off CO2
what is glycogenolysis?
degradation of glycogen, which is the main storage form of glucose in the body
a sudden decrease in urine output after kidney transplant may indicate what four things?
dehydration rejection urine leak into peritoneal space obstruction from hyperplasia, kinking, etc
what causes the dry mucous membranes and loss of skin turgor with HHNS?
dehydration from polyuria
what two androgens are released by the adrenal cortex?
dehydroepiandrosterone (DHEA) and androstenedione
what causes abdominal pain, nausea and vomiting with HHNS?
delayed gastric emptying caused by hyperglycemia
why is presentation of hypopituitarism variable?
depends on which hormones are deficient
what three drugs may be used for central/neurogenic DI?
desmopressin (DDAVP) vasopressin lypressin
what can put residents of underdeveloped countries at higher risk for goiters?
developed countries obtain iodine via salt, but 3rd world countries don't have access to iodized salt; thyroid needs iodine to make thyroid hormone
patients with thyroiditis should report what three changes?
difficulty breathing/swallowing swelling of face/extremities rapid weight gain/loss
what is a nontoxic goiter?
diffuse enlargement of thyroid gland normal thyroid hormone levels (benign)
how does hypoglycemia present differently in the elderly?
elderly have more severe symptoms and they may be missed (attribute neuro changes to dementia or other problems)
what will urine sodium be like with SIADH?
elevated >30
how will plasma cortisol levels be affected by cushing syndrome?
elevated in the morning
how does T3 and T4 change with hyperthyroidism?
elevated or normal if subclinical
what is a goiter?
enlargement of the thyroid gland
how can infection/sepsis/illness lead to DKA?
epinephrine release triggers fight/flight and liver to make glucose, resulting in hyperglycemia
what is the goal of a stem cell transplant?
eradicate diseased tumor cells and/or clear the marrow of its components to make way for engraftment of the transplanted, healthy stem cells
how often should I&O checks be done for the patient with DKA?
every hour
why does cushing syndrome result in an increase in sodium and decrease in potassium?
excess aldosterone, which stimulates kidneys to retain sodium and water and excrete potassium
what are 7 precipitating factors of hypoglycemia?
excessive admin of insulin/oral antidiabetic agents consumption of too little food/NPO high activity levels beta blockers hormonal changes diarrhea/vomiting ETOH consumption
what is hirsutism?
excessive hair growth in unusual places
what does excess ADH cause?
excessive water resorbed>>dilutional hyponatremia
what is glycosuria?
excreting glucose into urine
what causes secondary adrenocortical insufficiency?
exogenous corticosteroids can suppress the hypothalamic-pituitary-axis and suppress ACTH secretion - if d/c them too quickly, then could have insufficiency
what are 11 s/s hyperthyroidism
exophthalmos bruit HTN dyshrythmia palpitations a-fib weight loss fine, silky hair diaphoresis fatigue insomnia
true or false? most kidney transplants from cadavers do not last very long
false; 90% 1-yr graft survival rate
true or false? if your patient is brain dead, it is the nurse's role to approach the family to discuss organ donation
false; LOPA rep will approach them
true or false? if you have reason to believe that a dying patient is not a candidate for organ donation, there is no need to call LOPA
false; call for all deaths and agency will determine if they're a candidate
true or false? a kidney taken from the left side of the body must also be transplanted into the left side
false; can go on either side
true or false? during kidney transplant, the diseased kidney is removed and the new kidney is put in its place
false; diseased kidney remains in place unless there's a malignancy or something
true or false? for brain death organ donors, all supplemental supports are withdrawn before the organs can be procured
false; left on support so organs can perfuse while the procedure is performed
true or false? more critically ill patients are considered last for organ transplant since they are higher risk
false; more critical = higher priority to receive organ
how does chronic rejection manifest with kidney transplants? (2)
fibrosis and glomerulopathy
what does cortisol do? (2)
fight or flight anti-inflammatory
where may patients experience tingling/burning/numbness with hypocalcemia?
fingertips, toes and lips
what medication can be used to replace mineralocorticoids with adrenal insufficiency?
fludrocortisone acetate
what is the priority of treatment for DKA?
fluid and electrolyte balance
what are five important aspects of nursing care for SIADH treatment?
fluid restriction mouth care daily weights constipation seizure precautions
what is the first priority after a kidney transplant?
fluid/electrolyte balance
why may psychosocial disorders be a contraindication to organ transplant?
follow-up after transplant is important and need to be compliant with meds and follow-up, have good support system and be stable
when will patients with an organ transplant be prescribed monoclonal antibodies?
for prevention and treatment of acute rejection episodes - added to regimen if experiencing acute rejection until under control
where are the parathyroid glands located?
four little glands on back of thyroid
how can fluid replacement for HHNS/DKA lead to cerebral edema?
give too much insulin too quickly and fluids shift from vascular to cellular space
the adrenal cortex secretes what three things?
glucocorticoids mineralocorticoids androgens
what can happen if hashimoto's progresses rapidly?
goiter can obstruct breathing
what is hashimoto's?
gradual destruction of thyroid tissue by antibodies
most cases of hyperthyroidism are caused by what?
graves disease
what is a cause of hyperthyroidism?
graves disease
what will urine specific gravity be like with SIADH?
greater than 1.030
what is diabetes insipidus?
group of conditions associated with a deficiency of production or secretion of ADH or a decreased renal response of ADH (have enough, but kidneys don't respond)
what is the most common cause of a hypothyroid goiter?
hashimoto's
your patient comes to the ER with complaints of SOB and voice changes. they have a history of hypothyroidism. what do you suspect?
hashimoto's
without preservation methods, describe the window of time we have for heart, lung, liver, pancreas, kidney, and intestinal transplants
heart - 4-6hr lungs - 4-6hr liver - 8-12hr pancreas - 12-18hr kidney - 24-36hr intestines - 8-16hr
s/s heart transplant rejection are similar to what?
heart failure
why is it important to consider body size for a heart transplant?
heart must fit in rib cage
calcineurin inhibitors are used most commonly for what three types of organ transplants?
heart, liver, and kidney
what is another name for a stem cell transplant?
hematopoietic stem cell transplantation (HSCT)
how should you monitor response to DI treatment?
hemodynamic measurements like HR, BP, CVP, and PA pressure
what is used to measure glycemic control and regimen compliance over the last 2-3 months?
hgb A1C
is serum sodium high or low with HHNS?
high
what is leukocytosis?
high WBC
describe the pathophysiology of HHNS
high cellular glucose levels produce an osmotic gradient>>osmotic diuresis severe dehydration urinary loss of NA, K, Mg, Ca, Ph - electrolyte imbalances hyperglycemia (600 - 2000) altered LOC, progressing to seizure, shock, coma, and death
is BUN/Cr high or low with HHNS? why?
high; dehydration leads to prerenal kidney injury, which can lead to acute intrarenal injury
what is oxytocin?
hormone produced by the hypothalamus and secreted by the pituitary gland for childbirth and other functions
what is a toxic nodular goiter?
hormone secreting nodules associated with hyperthyroidism
what is HLA?
human leukocyte antigen; gene complex encoding the major histocompatibility complex (MHC) proteins in humans. these cell-surface proteins are responsible for the regulation of the immune system in humans
what medication can be used to replace glucocorticoids with adrenal insufficiency?
hydrocortisone
are goiters more common with hyper or hypothyroidism?
hyper
what are the three types of graft rejection?
hyperacute, acute, and chronic
what are two other names for hyperglycemic hyperosmolar nonketotic syndrome?
hyperglycemic hyperosmolar state (HHS) and hyperglycemic hyperosmolar nonketotic (HHNK) syndrome
what causes the polyuria/osmotic diuresis of DKA?
hyperosmolarity, so body tries to equal out by shifting water from intracellular to intravascular space
what are 4 s/s addison's disease?
hyperpigmentation of buccal mucosa and skin creases diffuse tanning/freckles orthostatic hypotension scant hair in pubic/axillary areas
what are two corticospinal signs of ODS?
hyperreflexia and bilateral babinski sign
what will serum osmolarity be like with SIADH?
hypo-osmolar <280
hypoparathyroidism will result in s/s of what?
hypocalcemia
what causes orthostatic hypotension with addison's disease?
hyponatremia and hyperkalemia from deficit of aldosterone
what is a major complication of treatment for DI?
hypotension
what are 12 s/s addisonian crisis?
hypotension tachycardia dehydration hyponatremia hyperkalemia hypoglycemia fever weakness confusion vomiting diarrhea pain in abdomen/lower back/legs
what are 12 clinical manifestations of HHNS?
hypotension tachycardia warm/dry skin (unless in shock) dry mucous membranes polyuria loss of skin turgor weight loss sunken eyeballs abd pain n/v neuro changes (seizures, LOC) shallow breathing
describe how the adrenal cortex is stimulated to release hormones
hypothalmus secrets corticotropin-releasing hormone (CRH) and stimulates the secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary.
what tonicity IV fluids should be used for DI?
hypotonic
how does iodine work for graves disease?
inhibit synthesis of T3 and T4 and decreases the vascularity of the thyroid
what does calcitonin do?
inhibits the transfer of calcium from bone to blood, increases calcium storage in bone, increases renal excretions of calcium and phosphorus to balance them out; important for bone strength!
what does FSH do? (3)
initiates the formation of follicles in the ovary stimulates follicle cells to secrete estrogen stimulates sperm production in testes
how do you mix NPH and regular insulin? why do you do it this way?
inject air into NPH, air into regular, withdraw regular then withdraw NPH. prevents the contamination of regular with NPH. (RN- regular, then NPH)
what are three theoretical factors that might cause graves disease?
insufficient iodine supply, infection, stressful life
what are 6 precipitating factors of DKA?
insulin pumps infection/sepsis/illness pancreatitis trauma/surgery new onset type 1 noncompliance with insulin regimen
how does autonomic neuropathy affect response to hypoglycemia?
interferes with the counter regulatory mechanisms... don't respond to hypoglycemia with sympathethic symptoms like a normal person would
hypocalcemia that results in acute airway problems like laryngospasm may require what treatment?
intubation or tracheostomy
