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Anaesthesia for endocrine
surgery
Adrenal surgery
Martin Feast
18th Nov 2014
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Adrenal surgery
Indications
Surgical approach
Phaeochromocytoma
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Indications for surgery
Phaeochromocytoma
Cushing’s syndrome
Cushing’s disease
Adrenal cancer
Metastatic cancer?
Non functioning tumour
Conn’s syndrome
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Conn’s syndrome
Primary hyperaldosteronism
Hypertension
Sodium / water retention
Hypokalaemia
65% unilateral adenoma
30% bilateral idiopathic hyperaldosteronism
Medical treatment with spironolactone before
surgery
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Adrenalectomy
Laparascopic surgery
Transperitoneal
Retroperitoneal
Open surgery
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Surgical emphysema
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Post-op analgesia
Remi vs fentanyl
PCA
Epidural
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Phaeochromocytoma
Presentation
Headaches
Hypertension
Palpitations
Episodic sweating
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Other presentations?
Incidentaloma
MI / ACS / Takotsubo cardiomyopathy
Screening (Von Hippel-Lindau, NF1, MEN,
family history)
Intra-operatively
Pregnancy
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Features
Ventricular arrythmias
Cardiomyopathy (including Takotsubo
cardiomyopathy)
Peripheral vasoconstriction
Haemoconcentration
Increased blood glucose
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Schematic representation of takotsubo
cardiomyopathy (A) compared to a normal
heart (B).
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Localization of tumour
CT
MRI
MIBG scanning
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MIBG scan
Metaiodobenzylguanidine
Radio-isotope
Iodine solution taken to prevent uptake by
thyroid
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Pre-op assessment
ECG
Arrythmias
Hypertrophy
Cardiomyopathy
Ischaemia
Infarction
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Pre-op assessment
ECHO
Looking for catecholamine associated
cardiomyopathy (high mortality)
Mandatory if any suggestion of heart failure
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Pre-op assessment
U&E
FBC
G&S
Glucose
Calcium
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Calcium?
MEN 2A
Medullary carcinoma of thyroid
Phaeochromocytoma
Parathyroid hyperplasia (80%)
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Pre-op management
Alpha blockade
Phenoxybenzamine / Doxazocin
Urapidil
Beta blockade?
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The anaesthetic
Pre-med?
Cannula, arterial line (awake)
Remi / induction agent / muscle relaxant
Hypotension
CVP line
Cardiac output monitoring?
Epidural vs PCA
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Intra-op
Lateral position
Can kink IVC
Keep paralyzed
Hypertensive crises
Phentolamine, labetalol, esmolol, magnesium,
GTN, sodium nitroprusside
Urapidil, nicardipine
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Urapidil
Competitive, selective short acting alpha1
antagonist
Onset of action 3 -10 mins
(phentolamine 15 secs)
Elimination half-life 2 – 6 hours
(phentolamine 19 mins)
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Urapidil Ann Fr Anesth Reanim. 1996;15(2):142-8. [Use of urapidil during surgery for pheochromocytoma].
7 patients, bolus or infusion intra-op to treat hypertension. 3 patients
had severe post-op hypotension.
World J Surg. 2013 May;37(5):1141-6. doi: 10.1007/s00268-013-1933-9.Urapidil in the
preoperative treatment of pheochromocytomas: a safe and cost-effective method.
30 patients, retrospective analysis. No significant differences in
hypertensive episodes in theatre. Reduced length of stay.
British Journal of Anaesthesia 92 (4): 512±17 (2004) Effects of perioperative a1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma
18 patients
3 days of iv urapidil for pre-op preparation
Concluded was a safe alternative to phenoxybenzamine
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Nicardipine
British Journal of Anaesthesia 92 (4): 512±17 (2004)
Dihydropyridine calcium-channel blocker
Recently granted UK license for life-threatening
hypertension
European Medicines Agency recommends only
give by continuous infusion
Onset 10-20 mins
Half life 2-4 hours
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Post op
Hypotension after ligation of adrenal vein
Sometimes need noradrenaline
Resistant due to alpha blockade
Vasopressin
Bleeding
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Hypoglycaemia
Alpha 2 receptor
Stimulation inhibits insulin secretion
Inhibition facilitates insulin secretion
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Questions?