Transcript Endocrine Emergencies in the OR

Endocrine Emergencies in
the OR
Jennifer Thomas-Goering, DO, MBA
Clinical Lecturer
University of Michigan
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Objectives
1. To review the physiology of the
Hypothalamic-Pituitary-Adrenal Axis
2. To review the pathology of common
endocrine diseases
3. To understand the perioperative
complications of thyroid disease and
pheochromocytoma
4. 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.
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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 Management
a. 2 sites for IV access to manage drips
b. 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 foley
f. Cooling blankets
g. 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. Rehydrate
3. Correct electrolytes
4. Cool
5. Esmolol infusion to keep HR<100
6. Propylthiouracil PTU 600mg loading
7. Lugol or K+ iodide 1 hr. after PTU
8. 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 Presentation
Hypothyroid
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
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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
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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
Mucosal Neuroma
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Neurofibromatosis
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Sturge-Weber
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Classic Symptoms
•Headaches
•Palpitations
•Diaphoresis
•Paroxysmal Hypertension
•Impending sense of doom
Triggers
•Stress
•Surgery
•Manipulation
•Medications
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•Pain
•Sympathetic stimulation
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 Criteria
1)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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References
1. 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 Pheochromocytoma
World 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: Pheochromocytoma
Essence of Anesthesia Practice, 2nd ed; 258, 2002