Endocrine Emergencies in the OR Jennifer Thomas-Goering, DO, MBA Clinical Lecturer University of Michigan www.flightglobal.com 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. synotix.com Hypothalamic-Pituitary-Axis commons.wikivet.net 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. www.rayur.com www.studyblue.com 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 dailymail.co.uk 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 www.mediahex.com 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 strangemilitary.com 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 http://www.gfmer.ch 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 http://www.flickr.com/photos/dokidok/2368947649 Neurofibromatosis www.documentingreality.com Sturge-Weber www.ghorayeb.com Classic Symptoms •Headaches •Palpitations •Diaphoresis •Paroxysmal Hypertension •Impending sense of doom Triggers •Stress •Surgery •Manipulation •Medications common.wikimedia.com •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 izifunny.com 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