endocrine emergencies in the or jennifer thomas-goering, do, mba clinical lecturer university of...
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Endocrine Emergencies in the OR
Jennifer Thomas-Goering, DO, MBAClinical Lecturer
University of Michigan
Objectives1. To review the physiology of the Hypothalamic-Pituitary-Adrenal Axis2. To review the pathology of common endocrine diseases3. To understand the perioperative complications of thyroid disease and pheochromocytoma4. Review current literature recommendations managing perioperative endocrine crises.
Endocrine Disease
Definition: over or underproduction of hormones responsible for physiologic responses to stress or homeostasis.
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Hypothalamic-Pituitary-Axis
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Thyroid Gland Dysfunction•Over or Under Production of:•T3 triiodothyronine•T4 thyroxine (tetraiodothyronine)•TSH (thyrotropin)
Hyperthyroid Disease States
Grave’s Disease
Thyroiditis
Struma Ovarii
Medicine
Clinical Presentation
Hyperthyroid
Hoarseness
Palpitations
Diarrhea
Anxiety
Heat Intolerance
Weight Loss
Tremulous
Clinical Correlate•45 year old female, presents to ED with nausea, vomiting, diarrhea, and abdominal pain. CT shows an inflamed appendix.•Vitals: •50 kg, HR 112, BP 198/105, 98% RA, Temp 38.2•Emergent Appendectomy is needed.
Hyperthyroid Management•History & Physical•Airway: snoring, orthopnea, OSA•CV: palpitations, chest pain, CHF•GI: diarrhea, lightheadedness•CNS: increased reflexes, anxiety, baseline mental status•Heme: loss skin turgor from dehydration, mild anemia
Anesthetic Managementa. 2 sites for IV access to manage dripsb. Arterial line for close monitoring of blood pressure, can also be used to guide volume status and blood gas analysis.c. Consider a PA catheter/TEE if concerned for heart failure or CM.d. Possible AFOI is concerns of tracheal involvement, intubate under spontaneous ventilation if concerned for sub-sternal involvement (CPB should be on stand by)e. Temperature sensing foleyf. Cooling blanketsg. Careful eye protection
Tracheal Deviation
Sub sternal Thyroid
Perioperative Anesthesia Management
- rehydrate due to chronic dehydration- preoxygenate well due to increased metabolic requirements- smooth induction, avoid ketamine or etomidate- judicious use of NMB
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Thyroid Storm•Medical Emergency: 10-50% mortality• Cardiac dysrhythmias, tachycardia, CHF, hyperpyrexia, delirium, coma, and death.
Induced by Severe Infection
Surgical stress
Labor and Delivery
Iodinated contrast medium
Management of Thyroid Storm
1. ACLS 2. Rehydrate3. Correct electrolytes4. Cool 5. Esmolol infusion to keep HR<1006. Propylthiouracil PTU 600mg loading 7. Lugol or K+ iodide 1 hr. after PTU8. Corticosteroids 100mg every 8 hours
Is it Thyroid Storm?
• not associated with muscle rigidity• no elevated creatinine kinase• no marked degree of metabolic and respiratory acidosis
• These are more common with MH
Hypothyroidism
•Incidence is about 0.5-0.8% population•Low levels of circulating T4 &/ T3
•No need to postpone elective surgery•No change in MAC
Hypothyroidism Disease
Cretin
Thyroidectomy
Hashimoto’s Thyroiditis
Hypothalamic Pituitary Dysfunction
Clinical PresentationHypothyroid
Snoring
Lethargy
Bradycardia
Constipation
Impaired Mentation
Fluid Retention
Decreased Reflexes
Clinical Correlate•70 year old female presents from assisted living for complaints of abdominal pain. Abdominal x-ray shows free air under the diaphragm. Surgeon calls you at 3 am for an emergency laparotomy. •BP 90/45, HR 50, Temp 35, RR 8, Sats 88% RA
Hypothyroidism•History & Physical:•Airway: snoring, orthopnea, OSA•CV: bradycardia, decreased CO, HTN•GI: constipation•CNS: sluggish reflexes, lethargy, slow mentation, cold intolerance, adrenal suppression•Heme: decreased platelet adhesiveness
From the Department of ENT & Head Neck Surgery and Department of Pathology1, SDM College of Medical Sciences & Hospital, Dharwad, Karnataka, India.
Myxedema Coma
•Medical Emergency: mortality 60%
•CHF•Obtunded•Bradyarrhythmias•Electrolyte abnormalities•Elevated CPK•Hypoxia
Anesthetic Management•1) Control airway•2) Central line and consider PA catheter •3) Arterial line•4) Levothyroxine 200-300 mcg IV over 10 min•5) Cortisol 100mg IV then 25 mg IV every 6hrs•6) Fluid and electrolyte resuscitation•7) Temperature sensing foley•8) Warm the patient•9) Patient to ICU post op
Clinical Correlate•58 year old male presents for melanoma removal from his arm and lymph node dissection. •PMH: HTN, HLD, DM, Anxiety, Chronic back pain, Smoker•Allergies: metoprolol•Meds: lisinopril, amlodipine, HCTZ, lovastatin, glipizide, xanax prn, vicodin•PSH: childhood T&A
History and Physical Exam•HEENT: Mall 1, normal airway exam•Pulmonary: course BS, clears with cough•CV: HR 85, BP 175/95, RRR, didn’t take his blood pressure medicine•Neuro: nervous, denies CVA, intact•Renal: normal per patient•GI: denies reflux, normal•Muscular: low back pain, no weakness•Skin: clammy
Induction
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Pheochromocytoma
•Rare neuroendocrine tumor of chromaffin cells in the adrenal gland secreting epinephrine, norepinephrine, dopamine and breakdown products.
•Incidence is 0.03- 0.04% in population
•50% of cases are diagnosed post-mortem
•Mortality can be 80% if diagnosed at time of anesthesia induction
Pheochromocytoma•90% spontaneous•10% familial•10% Bilateral, 10% extra-adrenal, 10% malignant
•MEN II: medullary thyroid cancer, primary hyperparathyroidism and mucosal neuromas•Neurofibromatosis•VHL•Ataxia-Telangiectasia •Sturge-Weber Syndrome
Sturge-Weber
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Classic Symptoms
•Headaches•Palpitations•Diaphoresis •Paroxysmal Hypertension•Impending sense of doom
Triggers
•Stress•Surgery•Manipulation•Medications•Pain•Sympathetic stimulation
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Diagnosis• Fractionated free metanephrine and normetanephrine levels by supine blood sample.• 24 hour urine for creatinine, total catecholamines, vanillylmandelic acid, and metanephrines• CT or MRI
Preparation for Surgery
•1. Phenoxybenzamine 10mg BID•2. Metoprolol 25-50 mg BID•3. Calcium Channel blockers•4. Metyrosine•5. Octreotide
Roizen Criteria1)no in-hospital blood pressure > 160/90 for 24 hours prior to surgery
2) blood pressure not <80/45 standing
3) no ST or T wave changes for a week prior to surgery
4) no more than 5 PVC’s in a minute
Day of Surgery• Arterial line• Central line• Nitroglycerin, nitroprusside infusions• Phenylephrine, Vasopressin, Norepinephrine infusions• Volume expanders, LR and Albumin• Magnesium Sulfate infusion
Summary-Functioning endocrine system is vital for homeostasis-Thyroid Storm is a life threatening condition-Myxedema Coma has under appreciated risks-Pheochromocytoma requires a high index of suspicion-Never underestimate the value of a thorough history & physical
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References1. Furman William: Endocrine Emergencies
ASA Anesthesia Refresher Course; vol. 35: 57-68, 2009
2 .Baskin Jack: American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism
Endocrine Practice; vol.8 no.6: 457-469, 2002
3. Baduni N, et al: Perioperative Management of a Patient with Myxedema Coma and Septicemic Shock
Indian Journal of Critical Care Medicine; vol. 14(4), 228-230, 2012
4. Woodrum D, Kheterpal S: Anesthetic Management of PheochromocytomaWorld Journal of Endocrine Surgery, Sept-Dec 2010; 2(3): 111-117
5. Holger Holldack: Induction of Anesthesia Triggers Hypertensive Crisis in a Patient with Undiagnosed Pheochromocytoma: Could Rocuronium be to Blame? Journal of Cardiothoracic and Vascular Anesthesia; 21:858-862, 2007.
6. Roizen M: PheochromocytomaEssence of Anesthesia Practice, 2nd ed; 258, 2002