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Periop . Cases on Endocrine Disorders

Periop . Cases on Endocrine Disorders. Thomas Maniatis Dec. 16 , 2010. Conflicts of Interest. None. Case. 65 female DM2 on glyburide 10 bid, pioglitazone 30 qd , metformin 1g bid Cataract OR Cholecystecomy Colectomy for colon CA. Issues to consider. Patient Factors

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Periop . Cases on Endocrine Disorders

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  1. Periop. Cases on Endocrine Disorders Thomas Maniatis Dec. 16, 2010

  2. Conflicts of Interest • None

  3. Case • 65 female • DM2 on glyburide 10 bid, pioglitazone 30 qd, metformin 1g bid • Cataract OR • Cholecystecomy • Colectomy for colon CA

  4. Issues to consider • Patient Factors • Type of diabetes • Treatments: Diet, oral agents, insulin • Adequacy of control: loose, optimal, tight • Surgical Factors • Minor, major • Timing • NPO starting when and lasting how long

  5. Preop control and periop complications • No high-quality data suggesting preop control impacts on periop complications • Small study suggested that HbA1c >7% associated with increased wound infections • Case-control study showed increased risk for wound infections if sugars > 11 (CABG)

  6. Effects of surgery on glucose control • Stress response causing increased glucose levels • glucagon, epi, GH, IL-6 and TNF-alpha

  7. Goals of therapy • Prevent ketoacidosis • Avoid marked hyper / hypo glycemias • Balanced fluids/electrolytes • “Tight” vs. “loose” control • Varying evidence for “tight” control • Improved outcomes in certain populations at cost of increased hypo’s • In general, “loose” control is acceptable

  8. Case • 65 female • DM2 on metformin 1 g bid, N 10-0-0-10 • Cataract OR • Cholecystectomy • Colectomy for CA • Radical Neck Dissection for neck mass

  9. Case • 55 male • DM1 on rapid 12-14-18-0, glargine 0-0-0-20 • Cataract OR • Neck Biopsy under GA (day surgery) • Cholecystectomy • CABG for CAD

  10. IV Insulin • How to write a protocol preop in stable patients • When to transition from IV to SC postop • How to transition from IV to SC postop

  11. IV Insulin • Protocols vary • Separate insulin/dextrose vs. combined GIK • Targets: tight vs. traditional • See Protocol • Calculation of starting dose • Baseline total daily dose/24 – “safety margin” of 30-50% • Dextrose depends on fluid sensitivity • D5 vs. D10 • Monitoring, NPO, adjustments • Start early to stabilize dose by OR

  12. IV insulin • Intraop • Managed by anaesthesia • Postop • Continue drips until no longer NPO • Plan transition to SC ahead of time

  13. IV–SC insulin transition post-op • Look at baseline dose pre-op • Compare with current “needs” and take into account stressors (infection, etc.) and PO intake • Hourly dose x 24 = total daily needs if control stable and eating well (and no infection…) • Preferred transition to 3 injections of short-acting with meals and 1 intermediate-long acting before bed while in hospital

  14. IV–SC insulin transition post-op • Sliding scale • Traditional vs. adaptive sliding scale • Monitor transition closely • Modify baseline doses daily • Closer to discharge, collapse regimen down to patient-appropriate protocol

  15. Case • 35 male • Pituitary surgery for tumour • Panhypopit. subsequently • Cort. 25/12.5, thyroxin, testosterone • Hernia repair • Cholecystecomy • Colectomy for mass

  16. Case • 65 female • PMR on pred. 15/d • Cataract • Inguinal Hernia • Esophageal resection for tumour

  17. Case • 50 male • Mod-severe COPD on intermittent prednisone 4 x per year, inhaled steroids • Exczema on topical steroids • Cholecystectomy • Pneumonectomy for tumour

  18. Effects of surgery on steroid secretion • Basal secretion • 8-10 mg/d of cortisol • Minor surgery • 50 mg/d • Major surgery • 75-100 mg/d (up to 200 mg/d in severe stress) • Timing • Biggest surge is immediately post-op (reversal of anaesthesia, extubation)

  19. Surgery and steroids • Assess reason for steroid exposure • Primary adrenal or pituitary disease vs. other • Assess magnitude of exposure • Dose and duration • Consider further testing of axis • ACTH stimulation using the 250 microg dose • Uncertain meaning • Need adequate time • Assess surgical “stress”

  20. Effects of steroids on adrenal axis • Likely not suppressed • Chronic use of < 5 mg of prednisone • Any patient on any dose of steroid for < 3 weeks • Likely suppressed • Any patient on > 20 mg of prednisone for > 3 weeks • Any patient with clinical Cushing’s • Intermediate • Everyone else!!

  21. Surgery and steroids • Supplement limited to immediate periop period • Hydrocortisone 50-100 mg IV pre-induction of anaesthesia, then 25-50 mg IV Q8h x 3 doses, then halve dose QD to baseline dose (or d/c) • Be aware of risks of steroids periop • Infections • Impaired wound healing

  22. Thyroid disorders and surgery • Poor evidence base supporting recommendations • Hypothyroidism • associated with intraop. hypotension in retrospective studies • Mild-mod: may choose to postpone elective surgery to optimize • Severe: only emergency surgery, give T4 and T3 urgently • Risk for myxedema coma • Hyperthyroidism • Beta blockers to control HR • Thionamides • Risk for thyroid storm

  23. Pheochromocytoma and surgery • Medical preparation focuses on avoiding hypertensive crises • Alpha blockade starting 7-10 days preop • phenoxybenzamine • Followed by beta blockade 2-3 days preop • Alternatives: Ca-channel blockers, metyrosine

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