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Endocrinology conditions
in the surgical patientKaren Choong MD
Department of Endocrinology, Diabetes and
NutritionUMMC
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Structure of the talk
Endocrine conditions in surgery
Pancreas
Diabetes management
Thyroid
Hyper- and hypothyroidism
Adrenals
Adrenal insufficiency
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Objectives
To be able to identify endocrinology disorders inthe peri-op period
To be able to demonstrate basic management ofendocrinology disorders during the peri-opperiod
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http://www.emedicinehealth.com
endocrine system
system of glands
each of which secretes a type of hormone
directly into the bloodstream
to regulate the body.
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DM management
in the surgical patient
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Diabetes Mellitus in the surgical patient
Find out if patient has DM
Find out what kind of DM regimen patient is on
On OHA On OHA and Bedtime insulin
On insulin
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What to do with diabetic meds?
Insulin
Depends on the type of insulin
Short-acting insulin analogshumalog/ glulisine/ novolog
Rapid actingregular
intermediate actingNPH/ lente/ ultralente
Take their evening dose as usual but reduce any morning doses by 1/3 ifthe surgery is in the morning, or by 1/2 if in the afternoon
long-acting analogslantus / levemir
Patients on long acting insulins such as Lantus should reduce theirevening dose prior to surgery by 20%.
Held onam ofsurgeryuntilregulardietresumed
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Oral hypoglycemics
avoid taking their oral diabetic medication the nightbefore surgery.
Tell patient not to take on day of surgery
Medications may be resumed the night after theirsurgery once they have resumed their diet.
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Preop(before surgery)
FBC
BUSE
HBAIC LIPIDS
ECG
CXR UFEME
VBG
HbA1c andglucose
Diabetic patient
Elective surgery
Pre-op assessment
Blood pressure Renal function
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BG > 10
Diabetic patient
Day of surgery
BG >4,
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Those on insulin drip
Need to check BG every 1-2 hr and insulin infusionadjusted
Need to check BUSE regularly
If sugar > 8 random should increase insulindoses in the current drip (usually there will be aninsulin gtt scale to follow)
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Emergency surgery
Convert to glucose infusion regimen andwithhold all diabetic medications
Check capillary blood sugar 2 hourly
Check BUSE regularly
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Intraop(during surgery)
Hypotension/ hypertension
Blood loss
Cardiac condition
Respiratory condition
Fluid overload
Electrolyte imbalance
Cerebral condition
Drug complications
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Postop(after surgery)
Typicallyas inpatient, will stop OHA and startSQ insulin
Minor surgery and patient ready to bedischarged
Can resume oral intake and can start OHA and/insulin
Intubated post surgeryrecommendation is tocontinue insulin gtt
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The amount of insulin required a day depends on a fewfactors:
- Body weight
- Insulin resistant state
- Stressors
- Renal status
- Concurrent medications- Appetite
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Assess risks of patientsHPT, hyperlipidemia,IHD, CRF, etc
Continue antihypertensive and cardiacmedications with sip of water in the am ofoperation
Adequate venous access
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Antibiotics prophylaxis for moderate or dirtyoperation
DVT prophylaxis
Stop smoking
Stop steroids
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Monitor for postop complications:
Infection
poor wound healing
cardiac condition
renal dysfunction
DVT
If immobilized:
dehydration, bedsore and pressure sore
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Thyroid diseases in the surgical patient
2 conditions:
Hyperthyroidism
Hypothyroidism
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Hyperthyroid Hypothyroid
Low or suppressed TSHElevated T3/T4 Elevated TSHLow T3/T4
Normalization of T3/T4** TSH lags behind
Normalization of TSH
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Why is it important to achieve
euthyroidism?
Hyperthyroidism Hypothyroidism
AVOID
THYROIDSTORM
AVOID
MYXEDEMACOMA
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Hyperthyroidism in the surgical patient
Elective surgery
Emergency surgery
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Elective surgery
If elective surgery,
Best to make sure patient is euthyroidbiochemically as well as clinically
Control thyroid status with antithyroidmedications (TFT stable for 3 or more months)
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Emergency surgery
If emergency operation,
Treat as thyroid storm eg, lugols iodine,dexamethasone, b blockers in addition to
antithyroid medications
Be careful of drugs that can affect thyroid
status eg Lithium, amiodarone
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Make sure cardiac status is optimized prior toelective or emergency surgery
Heart rate, atrial fibrillation, heart failure has tobe treated
For elective surgery, Graves eye condition has
to be stable
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Post-op monitor closely for worsening ofthyroid status if not controlled pre-op
After stress period over can withdraw lugols
iodine and steroid but continue antithyroidmedications and b-blockers
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Hypothyroidism
Elective surgery
Emergency surgery
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If elective surgery, ensure patient euthyroidclinically and biochemically for at least 3 monthsprior to surgery
L-thyroxine doses need to be optimized prior tosurgery
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If emergency surgery, can convert l-thyroxine(T4) to liotyronine(T3)
Lio-tyronine is faster acting
If needed intravenous T4 or T3 is available
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Make sure cardiac condition is optimised andhyperlipidemia optimised prior to surgery (ifelective)
Make sure any respiratory condition eg.obstructive sleep apnea controlled prior to
surgery
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Post-op monitor for myxedema coma if TFTnot desirable pre-op
Hypothermia and bradycardia may beanticipated
Cardiorespiratory function may be threatened
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After the patient is able to take orally and thepatient is out of sepsis, intravenous medicationcan be converted to oral preparation
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www.wikipedial.com
The adrenal system in the surgical
patient
Adrenal glands locatedsuperiorly to the kidneys
Cortex
Zona glomerulosa - aldo
Zona fasciculata - cortisol
Zona reticularisDHEAS/DHEA
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Surgery is one of the most potent activators ofthe HPA axis.
Plasma ACTH concentrations increase at thetime of incision and during surgery
The greatest ACTH and cortisol secretionoccurs during reversal of anesthesia, extubation,
and in the immediate postoperative recoveryperiod (? response to pain)
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So in the peri-surgical/immediate post-surgicalperiod, you expect the cortisol levels to beelevated
Suspect adrenal insufficiency if
hypotensive
hyponatremia
hypoglycemia
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Periop adrenal insufficiency
If no formerly known adrenal insufficiency, If time permits, check cortisol (would be high in
surgical patient) and, if low, begin steroid
replacement (hydrocortisone 100mg IV 3x/day) Most of the time, steroid replacement i.e
hydrocortisone is started and patient is tapered offsteroids with outpatient endo follow up to determine
status of the HPA axis. Other optionadminister dexamethasone 4mg IV
3x/day and do ACTH stimulation test
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The patient with
questionable HPA axis
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45 yo woman with longstanding history ofrheumatoid arthritis who is on longterm GCtreatment. She is now seeing you for pre-op
assessment for a right knee arthroplasty. Whatwould you do in terms of her GC replacement
during the perio-op period?
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Who is adrenally insufficient?
The following patients can be considered NOT to havesuppression of their hypothalamic-pituitary-adrenalaxis:
any dose of GC < 3 wks
Less than 5 mg/day of prednisone or its equivalent.
Patients on alternate-day glucocorticoid therapywhose dose is < the sum of physiologic replacement
for two days. Eg, replacement dose = prednisone 5mg/day
The sum of 2 days of replacement is 5+5 = 10
If pt on pred 5mg QOD sum of two days is 5 (5+0=5)
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Patients who should be assumed tohave functional suppression of hypothalamic-pituitary-adrenal function include:
> 20 mg/day of prednisone or its equivalentfor > 3 wks
Any patient who has clinical Cushing's
syndrome.
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45 yo woman with longstanding history ofrheumatoid arthritis who is on longterm GC
treatment who is now going for surgery.
- How long has she been on GC tx?
- How much GC/day?
- Assessment of S&S of Cushings
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When in doubt of HPA status
Do ACTH stimulation test
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The patient with known
adrenal insufficiency
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What do we do for a patient with known
adrenal insuffiency is going for surgery
Depends on the surgery
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For minor procedures such as herniorrhaphy hydrocortisone 25 mg/day is suggested for the day of operation only
return to the usual replacement dose on the second day.
For moderate surgical stress (eg,
cholecystectomy, joint replacement) hydrocortisone 50 to 75 mg/day in divided doses on the day of surgery and thefirst post-operative day
return to the usual dose on the second post-operative day (using oral orintravenous preparation as appropriate).
For major surgeries (CABG) 100150mg hydrocortisone dose/day for major surgical procedures x 2-3
days and the taper back to regular daily doses.
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The previous slide HC doses act as a guide
ALWAYS EXAMINE, MONITOR ANDREEVALUATE PATIENT
If BP low, presence of orthostatis, unexplainedhypoglycemia, electrolyte imbalance, sepsis,
surgical complicationsbleeding, renal failureetc
Patient may need to have HC dose titrated up
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Summary
Diabetes aim to optimise BP, A1c, glucose, renal function
If BG elevated on day of surgery Cancel and optimise glucose if elective surgery
Can start insulin gtt if surgery must continue
Thyroid disorders try to achieve euthyroidism before surgery
Adrenal insufficiency When in doubt, do ACTH stim (if time permits)
Can always start HC stress doses, taper and do ACTH stimlater
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THANK YOU
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Elective surgery
Fluids:
A diabetic does not need dextrose for fluids. Normalsaline (0.9% NaCl) would suffice
The only time D5 should be used is when patient isplaced on an insulin drip/infusion.