Anaesthesia for endocrine

surgery

Adrenal surgery

Martin Feast

18th Nov 2014

Adrenal surgery

Indications

Surgical approach

Phaeochromocytoma

Indications for surgery

Phaeochromocytoma

Cushing’s syndrome

Cushing’s disease

Adrenal cancer

Metastatic cancer?

Non functioning tumour

Conn’s syndrome

Conn’s syndrome

Primary hyperaldosteronism

Hypertension

Sodium / water retention

Hypokalaemia

65% unilateral adenoma

30% bilateral idiopathic hyperaldosteronism

Medical treatment with spironolactone before

surgery

Adrenalectomy

Laparascopic surgery

Transperitoneal

Retroperitoneal

Open surgery

Surgical emphysema

Post-op analgesia

Remi vs fentanyl

PCA

Epidural

Phaeochromocytoma

Presentation

Headaches

Hypertension

Palpitations

Episodic sweating

Other presentations?

Incidentaloma

MI / ACS / Takotsubo cardiomyopathy

Screening (Von Hippel-Lindau, NF1, MEN,

family history)

Intra-operatively

Pregnancy

Features

Ventricular arrythmias

Cardiomyopathy (including Takotsubo

cardiomyopathy)

Peripheral vasoconstriction

Haemoconcentration

Increased blood glucose

Schematic representation of takotsubo

cardiomyopathy (A) compared to a normal

heart (B).

Localization of tumour

CT

MRI

MIBG scanning

MIBG scan

Metaiodobenzylguanidine

Radio-isotope

Iodine solution taken to prevent uptake by

thyroid

Pre-op assessment

ECG

Arrythmias

Hypertrophy

Cardiomyopathy

Ischaemia

Infarction

Pre-op assessment

ECHO

Looking for catecholamine associated

cardiomyopathy (high mortality)

Mandatory if any suggestion of heart failure

Pre-op assessment

U&E

FBC

G&S

Glucose

Calcium

Calcium?

MEN 2A

Medullary carcinoma of thyroid

Phaeochromocytoma

Parathyroid hyperplasia (80%)

Pre-op management

Alpha blockade

Phenoxybenzamine / Doxazocin

Urapidil

Beta blockade?

The anaesthetic

Pre-med?

Cannula, arterial line (awake)

Remi / induction agent / muscle relaxant

Hypotension

CVP line

Cardiac output monitoring?

Epidural vs PCA

Intra-op

Lateral position

Can kink IVC

Keep paralyzed

Hypertensive crises

Phentolamine, labetalol, esmolol, magnesium,

GTN, sodium nitroprusside

Urapidil, nicardipine

Urapidil

Competitive, selective short acting alpha1

antagonist

Onset of action 3 -10 mins

(phentolamine 15 secs)

Elimination half-life 2 – 6 hours

(phentolamine 19 mins)

Urapidil Ann Fr Anesth Reanim. 1996;15(2):142-8. [Use of urapidil during surgery for pheochromocytoma].

7 patients, bolus or infusion intra-op to treat hypertension. 3 patients

had severe post-op hypotension.

World J Surg. 2013 May;37(5):1141-6. doi: 10.1007/s00268-013-1933-9.Urapidil in the

preoperative treatment of pheochromocytomas: a safe and cost-effective method.

30 patients, retrospective analysis. No significant differences in

hypertensive episodes in theatre. Reduced length of stay.

British Journal of Anaesthesia 92 (4): 512±17 (2004) Effects of perioperative a1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma

18 patients

3 days of iv urapidil for pre-op preparation

Concluded was a safe alternative to phenoxybenzamine

Nicardipine

British Journal of Anaesthesia 92 (4): 512±17 (2004)

Dihydropyridine calcium-channel blocker

Recently granted UK license for life-threatening

hypertension

European Medicines Agency recommends only

give by continuous infusion

Onset 10-20 mins

Half life 2-4 hours

Post op

Hypotension after ligation of adrenal vein

Sometimes need noradrenaline

Resistant due to alpha blockade

Vasopressin

Bleeding

Hypoglycaemia

Alpha 2 receptor

Stimulation inhibits insulin secretion

Inhibition facilitates insulin secretion

Questions?