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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?