Endocrinology Conditions in Surgical Patients

8/3/2019 Endocrinology Conditions in Surgical Patients

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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.

Documents

Endocrinology Conditions in Surgical Patients