Surgical consideration in particular patients:
Endocrine abnormalities
Poramaporn Prasarttong-Osoth, MD MSc FRCS(Glasg)Head, Neck and Breast unit
Department of SurgerySiriraj Hospital
Endocrine abnormalities
Thyroid
Parathyroid
Adrenal
Endocrine abnormalities:General concepts
Nonspecific clinical features
Disease organs Target organs
Primary disease or co-morbidities
Clinical features
HypertensionFaintingRecurrent kidney stonesRefractory epigastric pain/ peptic ulcerAnemiaOsteoporosisIncidentaloma
Thyroid abnormalitiesHyperthyroidism
Graves’ diseaseToxic multinodular goiterFactitious hyperthyroidism
HypothyroidismAutoimmune diseaseIatrogenic hypothyroidism
Thyroid hormone
Follicular cells
Colloid
Parafollicular cells
Thyroid hormoneMore than 99% bind to plasma protein
Tetraiodothyronine,Thyroxine (T4)Triiodothyronine (T3)
Monoiodotyrosine + Diiodotyrosine(DIT) Triiodotyronine (T3)
Diiodotyrosine + Diiodotyrosine Thyroxine (T4)
Factors affecting level of serum thyroid hormone
Increased TBG : High total T4 and T3Estrogen: Pregnancy, OCP, HRTDrugs: Methadone, 5-FU
Decreased TBG: Low total T4 and T3Liver diseaseAnabolic steroids, androgenGlucocorticoids
Thyroid hormoneT4 T3
Synthesis
Action
Serum
Half-life
93% 7%
Less potent More potent
Mainly from thyroid follicle
Mainly from peripheral conversion
7 days 1-3 days
HyperthyroidismSigns Symptoms
• Hyperactivity• Tachycardia/ AF• Systolic hypertension• Warm, moist skin• Tremor• Hyperreflexia• Muscle weakness
• Weakness, fatigue• Increase perspiration• Heat intolerance• Palpitation• Nervousness• Increase appetite • Weight gain• Menstrual disturbance
Thyroid hormoneCardiovascular system Increase O2 consumption, HR,
cardiac output, blood volume and pulse pressure
Respiratory system Increase O2 utilization and CO2 formation
GI system Increase appetite and intestinal movement
Musculoskeletal system
Increase activity of neuronal synapse and osteoclast
Basal metabolic rate Increase metabolism in nearly every type of cells
Achieve euthyroid stateAntithyroid drugs: 6-8 weeks
PropylthiouracilMethimazole
ß-blockersPropanololAtenolol
Corticosteroid: 5 daysHydrocortisoneDexamethasone
Lugol’s iodine: 7days
Thyroid crisis/Thyroid storm
Clinical featuresFever > 38.5°cTachycardiaConfusion/ agitationNausea/ vomitingHypertensionCongestive heart failureAbnormal liver function test
Thyroid crisis/Thyroid stormManagement
PTU 200-250mg PO every 6-8 hr
Lugol’s iodine 0.3ml PO every 8 hr
Sodium iodine 1.5g IV in 24 hr
ß-blockers IV
Digitalis
Hypothyroidism3-5/1,000 in female0.6/1,000 in male
Autoimmune thyroiditisIodine deficiencyIatrogenicDrugs (amiodarone, lithium)Congenital
HypothyroidismDepression of myocardial functionDepressed spontaneous ventilationReduced plasma volumeAnemiaHypoglycemiaHyponatremiaImpaired liver metabolismRisk of hypothermia
HypothyroidismManagement
Levothyroxine (T4) supplement
6-8 weeks
? Subclinical hypothyroidism
Parathyroid dysfunctionHyperparathyroidism
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tertiary hyperparathyroidism
HypoparathyroidismIatrogenicAutoimmune disease
Calcium homeostasisCalcitonin
Hypercalcemia: causes
Metastatic bone diseaseHyperparathyroidismSarcoidosisHyperthyroidismMultiple myelomaVitamin D overdose
Hypercalcemia: managementHydration
Drink 4-6 liters/dayIV fluid
Diuretics: loop diuretics!! Volume replacement and hypo K
BisphosphanatesPamidronate 60-90mg IV3 days to act, last 3 weeks
CalcitoninLast 48 hr
Perioperative care for 2°HPTDialysis
one day preop.24-48 hr postop.
Correct postop hypocalcemiaOral/IV calcium supplementOral vitamin D3correct hypomagnesaemia
Observe bleedingomit heparin use in dialysis a day before surgeryaware of platelets dysfunction in uremia
Adrenal dysfunctionAdrenal cortex
Zona glomerulosa Aldosterone
Zona fasciculata Cortisol, DHEAZona reticularis Estrogen, Androgen
Adrenal medullaAdrenalines, Noradrenalin and Dopamine
Adrenal tumour
Corticol tumour/ Diffuse hyperplasiaCushing’s syndromeConn’s syndromeAdrenogenital syndrome
Pheochromocytoma
Cushing syndrome
ObesityLoss of connective tissueHirsutism Muscle weaknessOsteoporosisHypertensionGlucose intoleranceDelayed wound healingImpaired immune function
Adrenal crisisAddison disease
Bilateral adrenalectomy
Bilateral adrenal infarction/hemorrhage
Secondary adrenal failure
Adrenal crisisClinical features
Hypotension/ shockAnorexiaNausea/vomitingAbdominal painFeverLethargyHypoglycemia
Adrenal crisis: managementRandom cortisol(<10μg/dl) and ACTH
Fluid resuscitation with 0.9% saline
Hydrocortisone 100mg IV every 6-8 hr
Identify and treat the precipitating causes
ACTH stimulation test should not be used during critical period
Glucocorticoid supplement in maintenance dose
Thank you