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KEY POINTS

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KEY POINTS

  1. Endocrine diseases are common comorbid conditions in surgical patients.

  2. The patient’s type of diabetes mellitus must be known and the differing therapies for types 1 and 2 appreciated.

  3. Frequent monitoring of glucose levels is a mainstay in management of the diabetic patient undergoing anesthesia and surgery.

  4. General anesthesia may mask the signs and symptoms of hypoglycemia; signs of hypoglycemia (tachycardia, sweating) may be misinterpreted as “light anesthesia”.

  5. Tight perioperative glucose control is no longer generally recommended. Consider keeping glucose levels at <150-180 mg/dL.

  6. Hypothyroid patients may exhibit sensitivity to sedative and hypnotic drugs used perioperatively. Hemodynamic instability should be anticipated.

  7. Hyperthyroid patients may exhibit dehydration and hemodynamic instability and are at particular risk for tachydysrhythmias, metabolic or vascular decompensation, and thyroid storm.

  8. The airway is a key consideration in patients undergoing thyroid surgery.

  9. Pheochromocytoma patients require careful preoperative preparation, and plans must be made to monitor and manage hemodynamic extremes during surgery.

  10. Glucocorticoid deficiency in patients at risk for adrenal insufficiency should be anticipated. Consider careful titration of supplemental steroid therapy.

  11. The implications of growth hormone excess (acromegaly) and adrenal steroid excess (Cushing disease) should be considered when preparing patients for pituitary surgery.

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INTRODUCTION

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Endocrine diseases are common comorbid conditions in patients undergoing surgery. The consequences of a coexisting endocrine disorder may have an impact on anesthetic and immediate perioperative management. Diabetes mellitus (DM) is the most common comorbid endocrine condition, affecting as many as 20% of patients scheduled for surgery and requiring anesthesia.1-3 Of potential importance for understanding factors influencing surgical outcomes, Abdelmalak and colleagues report that a significant proportion of patients in the Cleveland Clinic system scheduled for noncardiac surgery had either undiagnosed diabetes (10% of patients) or impaired fasting glucose levels (11% of patients).4 Consequently, the overall prevalence of glucose metabolism disorders in the surgical population may be considerably higher than the aforementioned 20% figure. The prevalence of thyroid disease is approximately 20% in the general population, so large numbers of patients who present for nonendocrine surgery have concomitant diagnoses of a thyroid disorder.

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The surgical condition may result in part or entirely from the endocrine disorder. For example, DM is a major contributor to the development of vasoocclusive disease in the patient requiring peripheral vascular surgery. The surgery may directly target endocrine tissue, either for biopsy or for excision. The pathophysiologic implications of the endocrine lesion and of surgical manipulation of the diseased tissue must be understood in the context of anesthetic and perioperative management.3 The most common endocrine surgery involves the thyroid gland.

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Chapter 12 covers fundamentals of endocrine system physiology and pathophysiology of particular relevance to the anesthesiologist. This chapter reviews the immediate perioperative implications of major endocrine disorders and addresses the specific issues encountered in surgery for common endocrine pathologies.

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DIABETES MELLITUS

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Diabetes mellitus is a condition with an absolute (type ...

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