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Therefore, it is not surprising that endocrinopathies affect anesthetic management. This chapter briefly reviews normal physiology and pathophysiology of four.
Table of contents

Comparison of two drug combinations in total intravenous anesthesia: Propofol-ketamine and propofol-fentanyl.


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Effect of respiratory acidosis and alkalosis on plasma catecholamine concentrations in anaesthetized man. Clin Sci Lond ; Anesthetic techniques and parathyroid hormone levels: Predictor of surgical decisions. Kandaswamy C, Balasubramanian V. Review of adult tracheomalacia and its relationship with chronic obstructive pulmonary disease. Curr Opin Pulm Med ; Farling PA.

Thyroid disease. Procedure guideline for therapy of thyroid disease with iodine. J Nucl Med ; Complications of thyroid surgery: Analysis of a multicentric study on 14, patients operated on in Italy over 5 years. World J Surg ; Attenuation of pressor response and dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine.

Indian J Anaesth ; Diabeto-anaesthesia: A subspecialty needing endocrine introspection. Modifying cardiovascular risk in diabetes mellitus. Vinik AI, Ziegler D. Diabetic cardiovascular autonomic neuropathy. Circulation ; Diabetic autonomic neuropathy. Diabetes Care ; Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: The DIAD study: A randomized controlled trial.

JAMA ; Sulfonylureas and ischaemic preconditioning; a double-blind, placebo-controlled evaluation of glimepiride and glibenclamide. Eur Heart J ; Bajwa SJ, Sharma V. Peri-operative renal protection: The strategies revisited. Indian J Urol ; Midazolam modifies pancreatic and anterior pituitary hormone secretion during upper abdominal surgery. Site of action of fentanyl in inhibiting the pituitary-adrenal response to surgery in man.

Dexmedetomidine and clonidine in epidural anaesthesia: A comparative evaluation. Myocardial effects of halothane and sevoflurane in diabetic rats. Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine: Is this a cause for concern? Arch Intern Med ; Scherpereel PA, Tavernier B. Perioperative care of diabetic patients. Eur J Anaesthesiol ; Mechanisms of arterial hypotension after therapeutic dose of subcutaneous insulin in diabetic autonomic neuropathy. Cortisol is required for converting norepinephrine to epinephrine in the adrenal medulla and for producing angiotensin.

It acts as an anti-inflammatory agent and has multiple effects on carbohydrate, protein, and fatty acid metabolism. Stress stimulates increased cortisol release.

Cortisol raises blood pressure by augmenting catecholamine-induced vasoconstriction. Aldosterone is the principle hormone of this class and the major regulator of extracellular fluid volume and potassium homeostasis. Its production is regulated by the renin—angiotensin system and blood potassium concentration see Chapter 4.

Increased renin levels promote the conversion of angiotensinogen to angiotensin I.

Anesthetic considerations for endocrine diseases – an overview

Angiotensin II then stimulates aldosterone secretion. ACE inhibitors reduce the production of angiotensin II and aldosterone. Case report. Relato de caso. Correspondence to. This is a report on a patient with multiple endocrine abnormalities, who did not fulfill the criteria of known syndromes MEN and the clinical-anesthetic particularities that influenced the anesthetic management.

Table of contents

CASE REPORT: A year old female patient with episodes of hypoglycemia difficult to control, associated with Cushing's disease and prolactinoma without symptoms of pituitary compression and with normal thyroid and parathyroid. Investigation found a retroperitoneal mass of unknown origin which in face of the clinical presentation raised the hypothesis of insulinoma. The patient also referred to be a Jehovah's Witness. Biopsy of the mass by videolaparoscopy and enucleation of the insulinoma were proposed.

On physical exam the patient was overweight, had protruding teeth, she was classified as Mallampati 3 and had symptoms of sleep apnea. Pre-anesthetic medication consisted of oral midazolam 7.

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Central venous access and invasive blood monitoring were instituted. Intravenous infusion of D5W with electrolytes was instituted and capillary glucose levels were monitored every 30 minutes, which did not demonstrate any episodes of hypoglycemia during the surgery. The patient remained hemodynamically stable even during the pneumoperitoneum. She developed postoperative episodes of hypoglycemia, which motivated the re-operation.

Intraoperative monitoring is mandatory during removal of an insulinoma to avoid incomplete tumor resection. Multiple challenges in one patient demand the knowledge, by the anesthesiologist, of each obstacle and its interactions in order to devise strategies to control them. Patients with endocrine-metabolic disorders represent a challenge for the anesthesiologist regarding preoperative management and care during the anesthetic-surgical procedure.

This is the report of a young patient, Jehovah's Witness, with insulinoma, prolactinoma and Cushing's disease with an adrenal mass of unknown etiology, undergoing videolaparoscopy.

Anesthesia for Patients with Endocrine Disease

The presence of multiple factors that, when combined interfere with several organs and systems influencing the anesthetic management makes this case unique. The international literature stresses the preoperative management of multiple endocrine neoplasias in the form of a few reports and revisions, which were used to compare with the present case, although the patient did not fulfill the criteria for any of those disorders because she did not have thyroid or parathyroid compromise.

The approach of a patient with insulinoma was emphasized, since this was the main reason for the surgery at the time. A year old female patient, 1. The surgical management proposed included resection of the pancreatic tumor and biopsy of the mass by videolaparoscopy.


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The patient also had a pituitary macroadenoma that produced prolactin and ACTH, with classical stigmata of hypercortisolism, such as centripetal obesity, gibbosity, acanthosis nigricans, violacious striae, hypertension, acne and hirsutism Figure 1. The patient did not have any signs of cranial nerve compression. Laboratorial studies of the parathyroid were normal. She had a history of seizures related with the episodes of hypoglycemia. She rejected blood transfusion on religious grounds. Her airways were classified as Mallampati 3, having protruded teeth, short neck and symptoms suggestive of sleep apnea as complicating factors for ventilation and intubation Figure 2.

Her medications included captopril, bromocriptine, verapamil and valproic acid. The patient was admitted to the operating room on stage Ramsay 3; a peripheral venous access was established and initial monitoring included cardioscope D II and V5 derivations , pulse oximeter and non-invasive blood pressure. Using the technique of Seldinger the right subclavian vein was catheterized with a 7F double-lumen catheter and the radial artery was catheterized to record MAP.

The patient was intubated without intercurrences with visualization Cormack-Lehane 1. Capillary glucose levels were checked every 30 minutes varying from 79 to mg. Infusion of D5W with electrolytes was titrated according to test results.


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