Adrenal disease

Question 1

What are the adrenal glands?

size, location

What are the two parts?

How are they regulated?

Answer 1

• The adrenal glands are multifunctional and secrete a variety of hormones
• Located just above each kidney, no larger than a walnut and wighing < a grape
• Two parts of the adrenal glands:
  
  • Cortex (makes up 80-90% of gland)
    
    • zona glomerulosa
    • zona fasciculata
    • zona reticularis
  • Medulla (makes up 10-20% of gland)
• Regulation- by hypothalamus, anterior pituitary, and adrenal cortex (HPA axis)

Question 2

What does the adrenal cortex release?

Answer 2

• Glucocorticoids (cortisol)
• Mineralcorticoids (aldosterone)
• Androgens

Question 3

What does the adrenal medulla release?

Answer 3

• Epinephrine (80%)
• Norepinephrine (20%)

Question 4

What are the physiologic functions of the adrenal gland?

Answer 4

• Blood glucose regulation
• protein turnover
• fat metabolism
• Na, K, and Ca balance
• maintenance of cardiovascular tone
• modulation of tissue response to injury or infection
• Survival as a result of stress- most important

Question 5

What is cushing’s syndrome?

What are the two causes?

Answer 5

• Hypercorticism- excessive cortisol secretion
• ACTH dependent
  
  • Pituitary corticotroph tumors (microadenomas)
  • Non-endocrine tumors of lung, kidney, or pancrease that cause extopic corticotropin syndrome
• ACTH independent
  
  • benign or malignant adrenocortical tumors
  • (the adrenal gland releasing cortisol without being told to do so by the release of ACTH)

Question 6

What are the signs and symptoms of Cushing’s?

Answer 6

• Sudden weight gain (usually central)
• thickening of the facial fat (moon face)
• Electrolyte abnormalities
• systemic hypertension
• glucose intolerance
• menstrual irregularities
• decreased libido
• skeletal muscle wasting
• depression and insomnia
• osteoporosis

Question 7

How is cushings disease diagnosed?

Answer 7

• Plasma and urine cortisol levles
  
  • 24 hr urine- 17-hydroxycorticosteroids
  • plasma cortisol levels
  • if both are elevated, pt has cushing’s syndrome
• CRH stimulation test- used to determine cause of cushings
  
  • inject pt with CRH and if they have increase in ACTH then it is a pituitary adenoma. (isnt that supposed to happen???)
• Dexamethasone suppression test- Dexamethasone should suppress cortisol levels. W/pituitary adenoma, it will do that d/t negative feedback
  
  • if you have a lung ACTH releasing tumor or something on the adrenal, it will not have negative feedback
• Inferior petrosal sinus sampling- injecting with ACTH and measuring ACTH levels in sinuses and compare to a more peripheral site. Not often used.
• CT & MRI once diagnosis is confirmed

Question 8

How is cushings treated?

Answer 8

• Surgical
  
  • transphenoidal microadenectomy- via the sphenoid sinus to remove the adenoma from the pituitary gland
  • Adrenalectomy- remove the adrenal gland; may have to be removed bilaterally
• Irradiation

Question 9

What are your preoperative considerations for a pt with cushings syndrome?

Answer 9

• HTN- may be on medications, may have cardiac compromise d/t htn
• Intravascular volume- are they on diuretics? Often Spironolactone
• Electrolytes- hypokalemia, hypernatremia
• Acid/bas status- hypokalemic metabolic alkalosis
• Cardiac compromise- CHF
  
  • EKG, do they have angina?
• Diabetes- check BS
  
  • control with small amounts of insulin, 1-5 units q hour

Question 10

What are your positioning considerations for a pt with cushing’s syndrome?

Answer 10

• High risk of fractures- Osteoporosis and osteomalacia
• Obesity- but oddly distributed fat (cone shaped arm, difficut to fit with appropriate BP cuff)
• Use appropriate padding
  
  • may need to ramp d/t fat pad on back of neck
• Check position throughout case
• Be careful when moving to and from stretcher, very fragile

Question 11

Patients with Cushing’s syndrome have muscle weakness. How can we address this?

Answer 11

• Hypokalemia is a contributing factor- treat pre-op with 80-100 mEq/day oral K
• Decrease doses of muscle relaxants
• Use a peripheral nerve stimulator
  
  • maintain 1 or 1/2 twitch at all times if possible so you know you can reverse
• May need post-op ventilatory support

Question 12

What medication do you need to give a pt who has had a unilateral or bilateral adrenalectomy?

Answer 12

• 100 mg glucocorticoid/24 hours- usually started intraoperatively
• Dose is reduced over 3-6 days to a maintenance dose
• may also need mineralcorticoid supplementation
• continued therapy may not be needed if only one glad was removed–depends on the function of the remaining gland

Question 13

How much blood loss do you expect to see with an adrenal removal surgery?

Answer 13

• May be significant blood loss
• Type and screen before case (laproscopic)
  
  • type and cross for major surgery (open)
• CVP/swan
• A-line

Question 14

What do you need to consider regarding anesthetic agents for a pt with cushing’s syndrom or an adrenal surgery?

What about epidural?

Answer 14

• Drugs or techniques are not likely to influence attempts to decrease cortisol levels
  
  • all inhaled agents depress adrenal response to stress and ACTH
  • Etomidate- inhibits enzymes involved in cortisol and aldosterone synthesis- long term infusion can cause adrenocortical suppression
• Changes caused by anesthetic agents or drugs are insignificant when compared to the increase in cortisol secretion with surgical stress
• Can do an epidural but it might be difficult to get d/t osteoporosis
  
  • other option for post-op pain is a PCA pump

Question 15

What are some complications you might expect in a transphenoidal microadenomectomy surgery?

Answer 15

• VAE
  
  • pt will be in high sitting position, will need central line and doppler to monitor
• transient diabetes insipidus
• meningitis

Question 16

What are some complications you might expect for an adrenalectomy surgery?

Answer 16

• Laparoscopic
  
  • always be prepared for a laproscopic procedure to become an open procedure
  • insufflation and all the problems that go along with that
• Open
  
  • pulmonary complications post op

Question 17

What is Conn’s syndrome?

Answer 17

• Primary hyperaldosteronism
• Excess secretion of aldosterone from a functional tumor
  
  • occurs more in women than men; rarely in children

Question 18

What causes secondary hyperaldosteronism?

Answer 18

• increased circulating renin stimulates the release of aldosterone

Question 19

What are the signs and symptoms of Conn’s disease?

Answer 19

• Systemic HTN- d/t aldosterone induced Na retention and increased fluid retention
  
  • HA
  • DBP 100-125 mmHg
  • may be resistant to treatment
• Hypokalemia
  
  • skeletal muscle cramps or weakness
  • metabolic alkalosis

Question 20

What are your anesthesia considerations for hyperaldosteronism?

Answer 20

• Correct decreased K level and HTN (Spironolactone)
• Assess cardiac/renal status
• Avoid hyperventilation which may further decrease K
• Monitors: A-line, swan
• Adequate fluids w vasodilators or diuresis
• Check acid/base and electrolytes frequently
• exogenous cortisol 100 mg every 24 hours- for removal or manipulation of adrenal gland

Question 21

What is Addison’s disease?

Answer 21

• Primary adrenal insufficiency
  
  • most commonly idiopathic or autoimmune
  • no symptoms until 90% of adrenal cortex has been destroyed
• Deficiency of all adrenal cortex secretions:
  
  • mineralcorticoids
  • glucocorticoids
  • androgens
• Other causes:
  
  • cancer
  • HIV
  • bacterial and fungal infections

Question 22

What are the signs and symptoms of Addison’s disease?

Answer 22

• Chronic fatigue
• muscle weakness
• hypotension
• wt loss
• anorexia, N/V/D
• increased BUN and hemoconcentration due to hypovolemia
• hyponatremia
• hyperkalemia
• hypoglycemia
• abdominal or back pain
• hyperpigmentation in sun-exposed areas and the distal extremeties
  
  • b/c these hormones stimulate melanocyte production

Question 23

How is Addison’s disease diagnosed?

Answer 23

• Baseline plasma cortisol level <20 mcg/dL ???
  
  • nml am cortisol = 10-20
  • nml 3-4 pm cortisol = 3-10
• Cortisol level <20 mcg/dL after ACTH stimulation test
  
  • Cortisol levels are measured 30 to 60 minutes following administration of ACTH
  • Normal response is a plasma cortisol level >25 mcg/dL
• Positive test yields a poor response to ACTH and is indicative of adrenal cortex impairment

Question 24

What is an addisonian crisis?

Answer 24

• Addisonian crisis is triggered in a pt who is dependent on exogenous steroids and do not receive enough during stress
• Stress leads to circulatory collapse
  
  • hypoglycemia
  • electrolyte imbalance
  • depressed mentation
• Rx: IV cortisol 100 mg q 4-6 hour for 24 hours
  
  • D5 0.9 NS
  • hypovolemic- replace with colloid or whole blood
  • Inotropic support

Question 25

What are the steroid management recommendations for a pt with addison’s disease have a surgery?

Answer 25

• Administer exogenous corticosteroids
  
  • If on a daily dose, have them take it day of surgery
• 25 mg hydrocortisone for minor surgery
• 100 mg bolus hydrocortisone followed with infusion at 10 mg/hr OR 100 mg q 6 hours

Question 26

How should you handle intraoperative hypotension for a patient with Addison’s disease?

Answer 26

• Rule out usual causes of shock
• measure CVP- administer fluids
• Vasopressor- even if it doesnt have much effect before cortisol
• administer Cortisol 100 mg IV
• fluids
• invasive monitoring

Question 27

What labs are you conserned about for a pt with Addison’s disease before and during the case?

Answer 27

• Glucose- check pre-op and every hour
  
  • treat hypoglycemia with dextrose
• check electrolytes frequently
  
  • concern for K levels- consider avoiding LR

Question 28

What anesthetic medications do you need to be careful with in a patient with Addison’s disease?

Answer 28

• Avoid Etomidate!
• Inhalation Agents can suppress adrenal function AND cause myocardial depression
  
  • might want to do balanced technique with opioids and propofol
• Titrate muscle relaxants b/c pt already has muscle weakness
  
  • Use PNS!

Question 29

What causes hypoaldosteronism?

Answer 29

• Congenital deficiency
• Hyporeninemia- d/t long standing diabetes and renal failure and/or treatment with ACE inhibitors causing loss of angiotensin stimulation
• Nonsteroidal inhibitors of prostaglandin synthesis
  
  • may inhibit renin release and exacerbate condition in presence of renal insufficiency

Question 30

What are the signs and symptoms of hypoaldosteronism?

Answer 30

• Hyperkalemic acidosis
• Severe hyperkalemia
• hyponatremia
• myocardial conduction defects

Question 31

How is hypoaldosteronism treated?

Answer 31

• Mineralocorticoids- fludrocortisone
• Liberal sodium intake