Endocrine Emergencies in the OR

1. Jennifer Thomas-Goering, DO, MBA Clinical Lecturer University of Michigan Endocrine Emergencies in the OR

2. www.flightglobal.com

3. 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. Objectives

4. Definition: over or underproduction of hormones responsible for physiologic responses to stress or homeostasis. Endocrine Disease synotix.com

5. Hypothalamic-Pituitary-Axis commons.wikivet.net

6. Over or Under Production of: T3triiodothyronine T4thyroxine(tetraiodothyronine) TSH (thyrotropin) Thyroid Gland Dysfunction

7. Hyperthyroid Disease States

8. Clinical Presentation

9. 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. Clinical Correlate

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12. 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 Hyperthyroid Management

13. 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 Anesthetic Management

14. Tracheal Deviation

15. Sub sternal Thyroid

16. - rehydrate due to chronic dehydration - preoxygenate well due to increased metabolic requirements - smooth induction, avoid ketamine or etomidate - judicious use of NMB Perioperative Anesthesia Management

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18. Medical Emergency: 10-50% mortality Cardiac dysrhythmias, tachycardia, CHF, hyperpyrexia, delirium, coma, and death. Thyroid Storm

20. 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 Management of Thyroid Storm

21. not associated with muscle rigidity no elevated creatinine kinase no marked degree of metabolic and respiratory acidosis These are more common with MH Is it Thyroid Storm?

22. 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

23. Hypothyroidism Disease

24. Clinical Presentation

25. 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 Clinical Correlate

26. 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 Hypothyroidism

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28. From the Department of ENT & Head Neck Surgery and Department of Pathology1, SDM College of Medical Sciences & Hospital, Dharwad, Karnataka, India.

29. Medical Emergency: mortality 60% CHF Obtunded Bradyarrhythmias Electrolyte abnormalities Elevated CPK Hypoxia Myxedema Coma

30. 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 Anesthetic Management

31. 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 Clinical Correlate

32. 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 History and Physical Exam

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34. 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

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36. 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 Pheochromocytoma

37. Mucosal Neuroma http://www.flickr.com/photos/dokidok/2368947649

38. Neurofibromatosis www.documentingreality.com

39. Sturge-Weber www.ghorayeb.com

40. Headaches Palpitations Diaphoresis Paroxysmal Hypertension Impending sense of doom Classic Symptoms

41. Stress Surgery Manipulation Medications Pain Sympathetic stimulation Triggers common.wikimedia.com

42. Fractionated free metanephrine and normetanephrine levels by supine blood sample. 24 hour urine for creatinine, total catecholamines, vanillylmandelic acid, and metanephrines CT or MRI Diagnosis

43. 1. Phenoxybenzamine 10mg BID 2. Metoprolol 25-50 mg BID 3. Calcium Channel blockers 4. Metyrosine 5. Octreotide Preparation for Surgery

44. 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 Roizen Criteria

45. Arterial line Central line Nitroglycerin, nitroprusside infusions Phenylephrine, Vasopressin, Norepinephrine infusions Volume expanders, LR and Albumin Magnesium Sulfate infusion Day of Surgery

47. -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 Summary

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50. 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 References