Endocrine Considerations in Anesthesia

1
Endocrine Considerationsin Anesthesia

• Thyroid
• Diabetes
• Adrenal Gland
• Liver

2
Thyroidism
3
Thyroid Gland Hormones

• Thyroid Hormones
• Thyroxine (T4)
• Triiodothyronine (T3)
• A. Major regulators of cellular metabolic
  processes
• B. Essential for neurological and cardiopulmonary
  function

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Thyroid Gland Hormones

• Thyrotropin (TSH) produced in anterior Pituitary
  gland
• TSH secretion regulated by hypothalamus hormone
  thyrotropin-releasing hormone (TRH)
• (T4) (T3) regulation by TRH TSH balance

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Thyroid Gland Considerationsin Anesthesia

• Cardiovascular manifestations
• Heat regulation
• Metabolism
• Oxygen consumption

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Thyroid Gland Considerationsin Anesthesia

• Thyroid hormones directly affect tissue responses
  to sympathetic stimuli
• Beta-adrenergic ? by thyroid hormone
• Alpha-adrenergic ? by thyroid hormone

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Hyperthyroidism

• 1. Graves disease 20-40 y/o
• Predominantly female
• Opthalmopathy
• Dermopathy
• Club fingers
• 2. Thyroiditis

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Hyperthyroidism

• 3. Hashimoto
• (usually hypo but sometimes hyper)
• 4. Adenomas
• 5. Carcinoma
• 6. Amiodarone drug induced
• (rich in iodine ?thyrotoxicosis)

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Hyperthyroidism Symptoms

• Heat intolerance
• Nervous
• Weight loss
• Tachycardia
• Diarrhea

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Tests of Thyroid Gland FunctionLaboratory
Determinations

• Total plasma thyroxine (T4)
• Detects gt 90 of hyperthyroid patients
• Resin triiodothyronine uptake (RT3U)
• Clarifies if T4 changes are due to thyroid
  dysfunction or alterations in T4 - binding
  globulin

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Tests of Thyroid Gland FunctionLaboratory
Determinations

• Total plasma triiodothyronine (T3)
• Confirms diagnosis of hyperthyroidism
• Thyroid stimulating hormone (TSH)
• Confirms diagnosis of primary hypothyroidism

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Tests of Thyroid Gland Function

• Thyroid scan
• Demonstrates iodide-concentrating
• of the capacity of thyroid gland
• Ultrasonography
• Distinguishes between cystic and solid nodules
• Antibodies
• Distinguishes Hashimotos thyroiditis from
  cancer

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Differential Diagnosis of Thyroid Gland
Dysfunction

• T4 RT3U T3 TSH
• Hyperthyroidism Incr. Incr. Incr.
  Decr
• Hypothyroidism (P) Decr. Decr. Decr. Incr.
• Hypothyroidism (S) Decr. Decr. Decr.
  Decr.
• Pregnancy Incr. Decr. Normal
  Normal

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Hyperthyroidism Symptoms

• Anxiety
• Heat intolerance
• Fatigue
• Skeletal muscle weakness

15
Hyperthyroidism

• Goiter
• Tachycardia
• Atrial fibrillation
• Tremor
• Eye signs (proptosis)
• Weight loss

16
HyperthyroidismTreatment

• Antithyroid drugs
• (propylthiouracil, methimazole)
• Propranolol
• Radioactive iodine

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Subtotal ThyroidectomyComplications

• Airway obstruction
• Hypoparathyroidism

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Subtotal Thyroidectomy Intraoperative Hazards

• Circulatory disturbances
• Thyroid storm
• Cooled saline infusion
• Esmolol

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Subtotal Thyroidectomy Preoperative Measures

• Normalize thyroid function
• Utilize beta sympathetic blockers
• Avoid anticholinergic drugs
• Evaluate upper airway
• (computed tomography)

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HypothyroidismSymptoms Signs

• Lethargy
• Intolerance to cold
• Bradycardia
• Peripheral vasoconstriction
• Adrenocortical atrophy
• Hyponatremia

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HypothyroidismAdverse Responses

• Sensitivity to depressant drugs (opioids)
• Hypodynamic circulation
• Slowed metabolism (drugs)
• Impaired ventilatory responses

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Hypothyroidism Anesthetic Management

• Preoperative supplemental hydrocortisone
• Induction ketamine
• Maintenance ultrashort acting drugs
• Postoperative defer extubation until patient
• is responsive and normothermic

23
Parathyroid
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Parathyroid Gland Dysfunction

• Disturbance of calcium levels
• Muscle weakness
• Polyuria and polydipsia
• Abdominal pain, vomiting
• Somnolence, psychosis
• Insensitivity to pain

25
Hypercalcemia Signs

• Renal
• Decreased GFR, stone formation
• Cardiac
• Hypertension, prolonged P-R, short Q-T
• Gastrointestinal
• Peptic ulcer, pancreatitis
• Skeletal
• Bone demineralization
• Ocular
• Band keratopathy, conjunctivitis

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Hypocalcemia

• Acute symptoms and signs
• Perioral paresthesias
• Restlessness
• Neuromuscular irritability (positive Chvostek or
• Trousseau sign, inspiratory stridor)
• Chronic symptoms and signs (renal failure)
• Fatigue, muscle weakness
• Prolonged Q-T interval

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Diabetes
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Diabetes Mellitus

• Metabolic Changes IDDM NIDDM
• Nutrition Thin Obese
• Blood glucose Variable Stable
• Ketoacidosis Common Uncommon
• Requires insulin Yes Not always

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Diabetes MellitusInsulin-Dependent vs.
Non-Insulin Dependent

• Age of onset IDDM lt 16 y/o Onset abrupt
• (Juvenile Diabetes)
• Age of onset NIDDM gt35 y/o Gradual onset

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Diabetes Mellitus

• Manifestations
• Polyphagia
• Polydipsia
• Polyuria

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Diabetes Mellitus

• Ketoacidosis
• Autonomic neuropathy
• Blood vessel pathology
• Micro/macroangiopathy
• Retinopathy
• Atherosclerosis
• Nephropathy
• Cardiomyopathy

32
Diabetes MellitusOther Pathologic Changes

• Carpal tunnel syndrome
• Stiff joint syndrome
• Scleredema
• Hyperalgesia

33
Autonomic Neuropathy

• Orthostatic hypotension
• Resting tachycardia
• Gastroparesis(vomiting,diarrhea)
• Impotence
• Cardiac dysrhythmias
• Asymptomatic hypoglycemia
• Sudden death syndrome

34
Preoperative Insulin Traditional Approach

• Give 1/4 to 1/2 the daily dose of
  intermediate-acting insulin subcutaneously
• Add 1/2 unit of intermediate-acting insulin for
  each unit of insulin prescribed
• Start IV glucose 5-10 g/h

35
Preoperative Insulin Continuous IV Infusion

• Place 50 U. Regular Insulin in 1000 ml NS
• Give 10 ml/h
• Measure blood glucose q.h.
• Adjust infusion rate to keep glucose level at
• 120-180 mg/dl
• Turn infusion off for 30 min if glucose level
  falls below 80 mg/dl
• Provide sufficient glucose (5-10g/h) and
  potassium (2-4 mEq/h)

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Hyperosmolar HyperglycemicNonketotic Coma

• Hyperosmolarity
• Hyperglycemia
• Normal pH
• Osmotic diuresis (hypokalemia)
• Hypovolemia (hemoconcentration)

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Adrenal Gland
38
HyperadrenocorticismCushings Disease

• Hypertension
• Hypokalemia
• Hyperglycemia
• Muscle weakness

• Osteoporosis
• Obesity (cushingoid habitus)
• Poor wound healing
• Susceptibility to infection

39
HypoadrenocorticismAddisons Disease

• Weight loss
• Muscle weakness
• Hyperpigmentation

• Hypotension
• Hyperkalemia
• Hypoglycemia

40
Hyperaldosteronism Conns Syndrome

• Hypertension
• Hypokalemic metabolic alkalosis
• Muscle weakness
• Treatment 1.Supplemental potassium,
• 2. Spironolactone

41
Pheochromocytoma(Catecholamine - Secreting Tumor)

• Signs symptoms
• diaphoresis, tachycardia, headache
• Diagnosis
• paroxysmal hypertension
• localization by computed tomography
• urinary excretion of catecholamine metabolites
  (vanillylmandelic acid)
• Treatment prior to surgery
• alpha beta sympathetic blockade
• (phentolamine, dibenzyline, labetalol)

42
Pheochromocytoma Anesthetic Management

• Alpha beta antagonist therapy
• Supplemental cortisol
• General anesthesia preferred over regional
• Blood pressure control
• (Nitroprusside, Phenylephrine)
• Control of cardiac rate rhythm
• (Esmolol, Lidocaine)
• Neuraxial opioids

43
Pheochromocytoma Monitoring

• Pulmonary artery catheter
• Balance Electrolyte Status
• Glucose determinations
• Arterial catheterization

44
Hepatic Disease
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Liver Disease History

• Jaundice
• Gastrointestinal bleeding
• Untoward effects of prior anesthetics
• Decreased exercise tolerance

46
Physical Findings

• Hepatosplenomegaly
• Arteriovenous fistulas (spider nevi)
• Ascites
• Cardiomyopathy
• Encephalopathy

47
Hepatic Laboratory Findings

• Abnormal liver function tests
• Coagulopathy (PT, PTT increased)
• Thrombocytopenia
• Renal dysfunction (hypernatremia)

48
Changes in Hepatic Cirrhosis

• Increased pulmonary shunting
• Renal dysfunction (sodium retention)
• Ascites and edema
• Anemia, thrombocytopenia

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Changes in Hepatic Cirrhosis

• Decreased clotting factors
• (II, VII, IX, X)
• Hypoalbuminemia
• Hepatorenal syndrome
• Encephalopathy

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Differential Diagnosisof Hepatic Dysfunction
51
Bilirubin Overload (Hemolysis)

• Unconjugated
• Normal
• Normal
• Normal
• Normal

• Bilirubin
• Aminotransferases
• Alkaline phosphatase
• Prothrombin time
• Serum proteins

52
Hepatocellular Dysfunction

• Conjugated
• Increased
• Normal
• Prolonged
• Decreased

• Bilirubin
• Aminotransferases
• Alkaline phosphatase
• Prothrombin time
• Serum proteins

53
Causes of Postoperative Hepatic Necrosis

• Hypoxemia
• Ischemia
• Sepsis
• Viral Infection
• Pre-existing liver disease
• Drugs

54
Cardiovascular Changes Hepatic Cirrhosis

• Hyperdynamic circulation
• Increased cardiac output
• Decreased peripheral resistance
• Increased blood volume
• Arteriovenous fistulas

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Cardiovascular Changes Hepatic Cirrhosis

• Decreased hepatic blood flow
• Portal hypertension
• Decreased arterial flow
• Cardiomyopathy

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Liver Disease Risk Factors

• Bilirubin gt 3 mg/dl
• Albumin lt 3 g/dl
• Prothrombin time (seconds
• prolonged) gt 6
• Poor nutritional state
• Ascites
• Encephalopathy

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Preanesthetic Treatment(Liver Disease)

• Correct coagulation defects
• (vitamin K)
• Correct hypoalbuminemia
• Reduce edema
• (furosemide, mannitol)

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Liver Disease Jaundice

• Bilirubin overload
• (hemolysis from blood, hematoma)
• Cholestasis
• Intrahepatic (infection, drug-induced)
• Extrahepatic (bile duct injury, gallstones)

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Liver Disease Jaundice

• Hepatocellular injury
• Hypoxia or ischemia
• Drug-induced
• Exacerbation of pre-existing disease (stress)
• Viral hepatitis

60
Conditions that Lower Esophageal Sphincter Tone

• Obesity
• Pregnancy
• Hiatal hernia
• Reflux syndromes

61
Drugs that Decrease Esophageal Sphincter Tone

• Anticholinergics
• Opioids
• Volatile anesthetics
• Intravenous anesthetics

62
Drugs that Increase Esophageal Sphincter Tone

• Anticholinesterases
• Succinylcholine
• Metoclopramide

63
Causes of Upper GI Bleeding

• Incidence ()
• 27
• 23
• 14
• 13

• Duodenal ulcer
• Gastritis
• Varices
• Esophagitis

64
Causes of Upper GI Bleeding

• Incidence ()
• 8
• 7
• 3
• 5

• Gastric ulcer
• Mallory-Weiss tear
• Bowel infarction
• Idiopathic

65
Reducing Risk of Aspiration

• Nasogastric suction
• Metoclopramide
• H2 antagonists

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Reducing Risk of Aspiration

• Nonparticulate antacids (Sucralfate)
• Awake intubation
• Rapid sequence induction-cricoid pressure

67
Acute Pancreatitis Predisposing Conditions

• Alcohol abuse
• Gallstones
• Blunt abdominal trauma
• Penetrating peptic ulcer
• Cardiopulmonary bypass

68
Cholestasis

• Conjugated
• May be increased
• Increased
• May be prolonged
• May be increased

• Bilirubin
• Aminotransferases
• Alkaline phosphatase
• Prothrombin time
• Serum proteins

69
Laparoscopic Cholecystectomy

• Risk Factors
• Impaired venous return
• Carbon dioxide embolism
• Underventilation
• Gastric reflux (decompression desirable)
• Loss of hemostasis, requiring laparotomy

70
Open Cholecystectomy

• Risk factors
• Biliary spasm (opioids-Morphine? )
• Postoperative pain

71
Carcinoid Syndrome
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Carcinoid Syndrome

• Cutaneous flushing
• Labile blood pressure
• Diarrhea
• Bronchospasm
• Cardiac failure (cardiomyopathy)

73
Carcinoid Treatment

• Fluid resuscitation
• H1 and H2 antagonists
• Serontonin (5-HT) antagonists
• Bronchodilators
• Vasoactive drugs
• Octreotide