Endocrine Flashcards
Acromegaly
Consideration
Goals
Conflicts
Crises
Acromegaly
Considerations
Difficult airway:
Macroglossia & enlarged epiglottis, resulting in difficult bag-mask ventilation & direct laryngoscopy
Recurrent laryngeal nerve palsy, narrow glottic opening, subglottic narrowing (stridor)
Nasal turbinate enlargement; caution with nasal intubation & consider smaller ETT
Multisystem disease:
Cardiovascular:
Hypertension, left ventricular hypertrophy, diastolic dysfunction
Arrhythmias
Coronary artery disease, cardiomyopathy
Respiratory:
Obstructive sleep apnea
Pulmonary hypertension, right ventricular dysfunction
CNS:
Pituitary dysfunction
Potential for raised ICP
Peripheral neuropathies common
Endocrine:
Diabetes mellitus/hyperglycemia
Difficult patient positioning, access, monitoring, regional anesthesia
Radial arterial line contraindicated due to poor collateral circulation
Goals
Safely secure difficult airway: consider awake fiberoptic intubation with stridor & voice changes
Thorough cardiopulmonary examination, including volume status assessment
Conflicts
Avoidance of CPAP following trans-sphenoidal surgery
Post-operative pain vs. enhanced sedation/respiratory depression
Crises
Post-operative stridor (subglottic edema, vocal cord paralysis)
Endocrine emergencies
Diabetes insipidus, SIADH
Adrenocortical Insufficiency (Addisonian crisis)
Background
Considerations
Goals
Medications
Adrenocortical Insufficiency (Addisonian crisis)
Background
Primary Addisonian crisis commonly due to autoimmune destruction of adrenal gland; mineralocorticoid activity also lost
Secondary Addisonian crisis caused by ↓ ACTH production either from hypothalamic pituitary disease or from adrenal suppression from chronic steroids, mineralocorticoid activity usually preserved
Considerations
Potential life-threatening situation: shock, dehydration, hypotension
Physiologic abnormalities:
Cardiovascular:
Impaired myocardial contractility
Arrhythmias secondary to hyperkalemia
Volume status: dehydration can occur (2-3 L)
Electrolyte imbalance
Hyperkalemia
Hyponatremia (↓ level of consciousness, seizures)
Hypoglycemia (↓ level of consciousness, seizures)
Stress dosing of steroids pre-operatively:
Hydrocortisone 100mg IV q6-8h
Fludrocortisone if 1° adrenal insufficiency
Pharmacologic concerns:
↓ circulating catecholamines (consider vasopressin for hypotension)
Succinylcholine-induced hyperkalemia
Goals
Prevent perioperative cardiovascular collapse:
Steroid supplementation
Volume resuscitation
Correction of electrolyte abnormalities
Medications
Hydrocortisone 100mg IV q6-8h for 24h then taper to maintenance of 15-20mg PO qAM & 5-10mg PO qPM
Add maintenance fludrocortisone 0.05-0.2mg PO daily if aldosterone-deficient (1° adrenal insufficiency) when tapering hydrocortisone
Alcoholism
Considerations
Multisystem disease:
Alcohol Withdrawal & Syndromes
Alcoholism
Considerations
Multisystem disease:
CNS: peripheral neuropathy, Wernicke-Korsakoff syndrome (ocular, ataxia, confusion), cerebral atrophy/dementia
Cardiovascular: cardiomyopathy, palpitations, arrhythmias
GI: liver dysfunction/cirrhosis, esophagitis, gastritis, pancreatitis, malnutrition
Heme: pancytopenia
Endocrine/metabolic: hypoglycemia, hypoalbuminemia, electrolyte abnormalities (hypokalemia, hypomagnesemia)
MSK: myopathies, osteoporosis
Other addictions
Altered pharmacology:
Induction of liver enzymes
↑ MAC
Alcohol withdrawal syndromes & need for CIWA protocol (tremors, autonomic hyperactivity, DTs)
Alcohol Withdrawal & Syndromes
Earliest & most common:
Generalized tremors that may be accompanied by perceptual disturbances (nightmares, hallucinations), autonomic nervous system hyperactivity (tachycardia, hypertension, cardiac dysrhythmias), nausea, vomiting, insomnia, & mild confusional states with agitation
Symptoms usually begin within 6 to 8 hours after a substantial ↓ in blood alcohol concentration & are typically most pronounced at 24 to 36 hours
These withdrawal symptoms can be suppressed by the resumption of alcohol ingestion or by administration of benzodiazepines
Delirium tremens:
Occurs in ~5% of those experiencing withdrawal
Symptoms begin 2-4 days after alcohol cessation
Manifests as hallucinations, combativeness, hyperthermia, tachycardia, hypertension or hypotension, & grand mal seizures
Treatment:
First line = benzodiazepines (titrated to effect without loss of respiration)
Beta blockers to reduce tachycardia & hypertension
Fix metabolic abnormalities (potassium, magnesium, & thiamine)
Severe cases will need ICU admission & propofol infusion/dexmedetomidine & possible intubation
Mortality = 10% (usually due to hypotension, dysrhythmias, or seizures)
Wernicke-Korsakoff syndrome:
Wernicke’s encephalopathy:
Loss of neurons in the cerebellum
Acute syndrome requiring emergent treatment to prevent death & neurologic morbidity
Korsakoff’s psychosis:
Chronic neurologic condition
Loss of memory resulting from the lack of thiamine (vitamin B1), which is required for the intermediary metabolism of carbohydrates
Anorexia Nervosa
Considerations
Goals/Optimization
Anorexia Nervosa
Considerations
↓ gastric empyting & aspiration risk
Metabolic & electrolyte abnormalities:
↓Na, ↓K, ↓Mg, ↓PO4
Hypoglycemia
Osteoporosis
Metabolic alkalosis from vomiting
Cardiovascular dysfunction:
Hypovolemia
Cardiomyopathy (LV failure)
Mitral valve prolapse
Arrhythmias: ↑QTc, bradycardia
Autonomic dysfunction
Malnutrition:
Anemia
Thrombocytopenia
Osteoporosis, fracture risk
Risk of re-feeding syndrome
Coexisting psychiatric disease:
Possibly uncooperative
Medications
Goals/Optimization
Minimize aspiration risk: fasted, aspiration prophylaxis
Rule out cardiomyopathy & underlying arrhythmias
Assess functional capacity/ECG/echocardiogram
Fix underlying electrolyte abnormalities
Very careful with glucose management (risk of refeeding syndrome & electrolyte shifts with replacement)
Avoid hypothermia
Careful positioning with osteoporosis
Multidisciplinary management including consultation with internal medicine, endocrinology, psychiatry
Carcinoid
Background
Consideration
Goals
Conflicts
Carcinoid
Background
Carcinoid syndrome presents in approximately 20% of patients with carcinoid tumours, usually with hepatic metastases
“Carcinoid triad”:
Carcinoid heart
Diarrhea
Flushing
Implicated malignancies: neuroendocrine tumors in GI tract (midgut), bronchial tumors
Considerations
Tumor: mass effect, metabolic derangements, medications, & metastases:
Mass effect: hemoptysis, bowel obstruction
Metabolic derangements: flushing, diarrhea, hemodynamic instability, bronchospasm (serotonin-related)
Medications: octreotide
Metastases: liver dysfunction, raised ICP if brain metastases
Cardiovascular dysfunction (20-40%):
Right-sided valvular lesions (10% present with left-sided lesions)
Right ventricular dysfunction
Dysrhythmias (eg. SVT)
Constrictive pericarditis
Preparation & treatment of perioperative carcinoid crisis:
Symptoms include flushing, diarrhea, hypotension, hyperglycemia, bronchospasm
Carcinoid tumors can also secrete GH (acromegaly) & ACTH (Cushing’s)
Goals
Prevent, recognize & treat perioperative carcinoid crises
Triggers include:
Histamine-releasing drugs, vasoactive drugs, succinylcholine
Tumour manipulation
Hypovolemia, hypoxia, hypothermia, hypercarbia
Treatment of perioperative bronchospasm:
Avoid beta agonists, theophylline, epinephrine
Responds to:
Octreotide
Steroids
Histamine blockade (diphenhydramine)
Atrovent
Prevention & treatment of carcinoid crisis:
Must prophylax with octreotide 300-500mcg IV
During crisis: octreotide 100mcg IV boluses titrated to effect, or an infusion
H1 antagonists (diphenhydramine 25-50 mg IV)
Refractory hypotension:
Give fluids
USE: octreotide, phenylephrine, vasopressin
AVOID: epinephrine, norepinephrine, ephedrine
Conflicts
RSI (bowel obstruction) vs. titrated induction
RSI vs. need to avoid succinylcholine
Need for deep anesthesia vs. cardiovascular dysfunction
Bronchospasm vs. need to avoid adrenergic agents
Cushing’s syndrome
Considerations
Cushing’s syndrome
Considerations
Possible difficult airway: obesity, obstructive sleep apnea (OSA)
Cardiovascular:
Left ventricular hypertrophy, pulmonary hypertension/right ventricular failure, systolic & diastolic dysfunction
Hypertension, volume overload (↑ renin & glucocorticoid vascular reactivity)
Respiratory: possible OSA
Metabolic:
Hypokalemic metabolic alkalosis: mineralcorticoid effect of glucocorticoids
Diabetes: insulin deficiency
Osteoporosis: need for careful positioning
CNS: possible psychosis
Pharmacologic considerations:
Perioperative steroid replacement (stress dose & post-operative replacement)
Sensitivity to neuromuscular blockers (due to possible muscle weakness, hypokalemia, catecholamines)
Cancer considerations (mass effect, metabolic derangements, metastases, medications) if primary Cushing’s (adrenal adenoma)
Diabetes Insipidus (DI)
Background
Considerations
Treatment
Potential conflicts
Diabetes Insipidus (DI)
Background
Central DI:
↓ secretion ADH
Most often idiopathic or induced by trauma, pituitary surgery, or hypoxic or ischemic encephalopathy
Nephrogenic DI:
Normal ADH secretion but kidneys are resistant to its water-retaining effect
Diagnosis:
Dilute urine (<150 mOsm/L)
Hypernatremia (Na>150)
Hyper-osmolality (>290)
Considerations
Hypernatremia:
Altered level of consciousness, seizures, coma, hyperreflexia
Risk of intracranial hemorrhage with acute, severe hypernatremia
↑ MAC requirements
Volume depletion:
Resuscitate with normal saline initially
Associated conditions:
Neurogenic (pituitary surgery, traumatic brain injury, tumor, idiopathic)
Nephrogenic (chronic renal failure, lithium toxicity, hypercalcemia, hypokalemia, congenital, fluoride toxicity)
Treatment
Consultation with nephrology may be valuable
Treat hypernatremia by estimating water deficit & replacing with free water:
Water deficit = total body water x (Serum Na [ ]/140-1)
Central DI: desmopressin 1-2 mcg IV BID
Nephrogenic DI: hydrochlorothiazide/amiloride
Complications of treatment:
Avoid rapid overcorrection if chronic hypernatremia (goal = <10 mEq/day)
Cerebral edema, water intoxication, volume overload
Potential conflicts
Emergency surgery vs. need for optimization of electrolytes/volume status
Diabetes Mellitus
Considerations
Goals
Crises
Special Populations
Diabetes Mellitus
Considerations
Potential difficult airway (↓TMJ mobility, obesity)
Aspiration risk with gastroparesis
End organ disease:
Hypertension, coronary artery disease, left ventricular hypertrophy & cardiomyopathy
Peripheral vascular disease
Chronic kidney disease
Neuropathy
Autonomic instability
Chronic pain
Perioperative complications & management of blood glucose & medications:
Related to severity of disease & control of blood glucose (hypoglycemia)
DKA or HONK
Hypoglycemia
Related to end organ disease
Goals
Evaluate severity of end organ dysfunction
Perioperative management of elevated blood glucose: Canadian Diabetes Association guidelines suggests 5-10 mmol/L
If only on PO hypoglycemics at home: start IV insulin infusion at 1-2 units/hr
If on insulin at home, divide 24 hr dose by 24 & give 1/2 to 2/3 that per hour as an IV insulin infusion
Consider bolusing a few units up front
Preoperatively (see SAMBA guidelines below):
Type II diabetes, diet controlled: fast, check blood glucose
Type II diabetes, on oral hypoglycemics: fast, hold pills morning of surgery, check blood glucose
Type II diabetes, on insulin: fast, insulin dose depends on type (see below), start D5W infusion
Crises
Hyperglycemia (DKA, HONK)
Hypoglycemia
Special populations
Pregnancy:
↑ risk of DKA, HONK, pregnancy-induced hypertension, difficult airway, aspiration, pre-term labor, cesarean section, polyhydramnios, postoperative infection
For fetus:
Macrosomia (birth trauma, shoulder dystocia, cesarean section, postpartum hemorrhage)
Euglycemic DKA
Background
Considerations
Prevention
Euglycemic DKA
Background
Major adverse event in T2DM (rarely T1) taking SGLT2 inhibitors
Triggered by:
intercurrent illness, surgery, fasting, reduced carbohydrate intake
SGLT2 inhibitors:
Lowers blood glucose by inhibiting renal glucose reabsorption
e.g. canagliflozin, dapagliflozin, empagliflozin
Considerations
Timing: few hours to 6 wks post-op
Risk factors:
Reduced carb intake, volume depletion, concurrent illness, ↑ surgical stress, insulin being held, bariatric surgery, pregnancy
High degree of suspicion for serum/urine ketones
Signs:
Normoglycemia / moderate hyperglycemia
Metabolic acidosis with high anion gap
decreased serum HCO3
Ketonemia &/or ketonuria
Symptoms:
Excessive thirst / urination
Vomiting / dehydration / other sx of hypotension
Altered LOC
Weakness / tiredness / fatigue
Kussmaul respiration (deep, rapid)
Need to hold SGLT2i at least 24 hrs pre-op
Resume >24hrs post-operatively only when adequate PO intake
Prevention
Avoid dexamethasone
Hold SGLT2i at least 24-48 hr pre-op
Resume 24-48hrs post-op assuming normal PO intake
Good post-op pain control
Maintain euvolemia
Hyponatremia
Considerations
Management
Hyponatremia
Considerations
Acute vs. chronic hyponatremia
Central pontine myelinolysis from rapid overcorrection
Physiologic manifestations (severe = neurologic symptoms or < 120 mEq/L):
CNS: ↓ LOC, seizures, cerebral edema, central pontine myelinolysis
Hyper- or hypovolemia
Respiratory arrest
↓ MAC
Etiology:
Hypervolemia:
Congestive heart failure
Hypoalbuminemia (cirrhosis, nephrotic syndrome)
Renal failure
TURP syndrome
Euvolemia:
SIADH (stress, pain, post neurosurgery)
Psychogenic
Hypovolemia:
Cerebral salt wasting
Hemorrhage
Addison’s disease
Peritonitis
Edema from burns
Diarrhea
Diuretics
Management
Correct severe hyponatremia before surgery
Restore volume deficit
Normal saline 20mL/kg IV bolus prn
Restore plasma sodium concentration
Acute:
Generally restrict free water (500mL-1L/day) +/- diuretic
Severe hyponatremia (< 120mEq/L or presence of neurologic symptoms)
Hypertonic saline 3% 1-2 ml/kg/hr until Na>125
Loop diuretics
Sodium bicarbonate (1 mEq/ml) to terminate seizures: 0.5-1mL/kg boluses prn
Chronic: avoid rapid overcorrection (0.5-1 mEq/hr, < 8 in mEq in 24hrs)
SIADH: treat underlying cause & fluid restriction
Identify & treat mineralocorticoid deficiency
Hyperaldosteronism
Considerations
Optimization
Hyperaldosteronism
Considerations
Hypertension & end-organ dysfunction:
Cardiomyopathy
Cerebrovascular disease
Chronic kidney disease
Fluid & electrolyte abnormalities:
Hypokalemia (weakness, potentiates non-depolarizing muscle relaxants)
Metabolic alkalosis
Volume depletion
Hypomagnesemia
Associated endocrine disorders:
Acromegaly
Pheochromocytoma
Primary hyperparathyroidism
Medications such as spironolactone
Adrenalectomy:
Bilateral? Need steroids
Laparascopic vs. open (pain & disposition)
Optimization
Antihypertensive therapy
Correction of electrolyte abnormalities
Hyperkalemia
Considerations
Management
ECG changes
Hyperkalemia
Considerations
Emergency situation with potential for life threatening arrhythmias, cardiac arrest
Etiology:
Shift:
Metabolic or respiratory acidosis, diabetic ketoacidosis
Digoxin toxicity
Total body excess:
Rhabdomyolysis (malignant hyperthermia, crush injuries, burns)
Post cardiopulmonary bypass
Iatrogenic (IV or oral)
Hemolysis
Tumor lysis
Transfusion (massive transfusion, old packed red blood cells)
Renal failure
Hypoaldosteronism
Addison’s
Drugs (succinylcholine, ACE inhibitors, beta blockers, spironolactone, NSAIDs, cyclosporin)
Systemic effects
Arrhythmias
Muscle weakness
Drug interactions
Succinylcholine contraindicated
Non-depolarizer muscle relaxants: resistance
Management
Stabilize myocardium:
Calcium gluconate 100 mg/kg
Shift potassium intracellularly:
Insulin 0.1 units/kg + Glucose 0.5-1 g/kg (25 g for every 10 U insulin)
Sodium bicarbonate 1 mEq/kg
Ventolin 5-10 mg via nebulizer or 5 mcg/kg IV
Hyperventilation
Epinephrine
Eliminate potassium:
Furosemide 20-40mg IV
Kayexalate 30 g PR or PO
Dialysis
ECG changes
Mild (5.5-6.5 mEq/L): peaked T waves, prolonged PR interval (1st degree AV block)
Moderate (6.5-8 mEq/L): loss of P wave, prolonged QRS, ST segment elevation, ectopic beats/escape rhythms
Severe (>8.0 mEq/L): progressive widening of QRS, bundle branch blocks, fascicular blocks, sine wave, ventricular fibrillation, asystole
Diabetic Ketoacidosis
Diagnosis
Considerations
Conflicts
Crises
Management
Goals
Complications
Diabetic Ketoacidosis
Diagnosis
Glucose > 14
HCO3 < 18
pH < 7.3
+ ketones in urine/blood
Considerations
Life threatening anion gap metabolic acidosis (ketoacidosis)
CNS: ↓ LOC (hypovolemia, cerebral edema)
Cardiovascular: cardiac arrythmias, congestive heart failure
Hyperventilation (very high minute ventilation, caution with intubation & positive pressure ventilation)
Hypovolemia:
Osmotic diuresis (hyperglycemia)
Crystalloid volume replacement
Electrolyte abnormalities:
Depletion of potassium, phosphorus, magnesium
Hyponatremia (factitious hyponatremia)
Consequences of therapy:
Electrolyte abnormalities
Hypo/hyperkalemia, hypomagnesemia, hypophosphatemia
Hypoglycemia
Cerebral edema, central pontine myelinolysis
Address underlying cause:
Infection, trauma, intoxication (cocaine), pancreatitis, acute coronary syndrome
Medication noncompliance (insulin)
Conflicts
Resuscitation vs. emergency surgery
Severe metabolic acidosis vs. intubation/ventilation
Hypovolemia vs. aspiration risk (RSI)
Crises
Electrolyte abnormalities (hyper/hypokalemia, hypomagnesemia, hyponatremia)
Hypoglycemia
Cerebral edema (glucose correction without correcting hyponatremia)
Central pontine myelinolysis (rapid serum sodium correction)
Management
Treat as per hospital protocol in consultation with endocrinology
For example, see BC Children’s Hospital’s DKA protocol:
Goals
Normal anion gap (AG)
pH > 7.2
Potassium > 3.5
Bicarbonate > 20
Glucose < 13
Urine output 1 ml/kg/hr
Volume replacement:
Normal saline to correct hypovolemia (3-5L deficit)
Then slow to maintenance (up to 500ml/hr)
Change to D5NS when glucose < 14
Add potassium to IV fluids once < 4.5 & urinating
Insulin R
Start infusion at 0.14 u/kg/hr (10units/hr in 70kg male) OR give 0.1 u/kg bolus followed by infusion 0.1 u/kg/hr
DO NOT start insulin if potassium <3.3
Glucose goal 10-15 mmol/L
When glucose <11: add D5W to solution
Potassium management
If < 3.3: DO NOT start insulin, give 20-30 meq/hr of potassium until K > 3.3
If > 3.3 & < 5.3: give potassium 20meq/L of fluid
If > 5.3: Do NOT give potassium
Frequent monitoring: ABG, electrolytes (AG), BUN, creatinine, osmolality, plasma & urinary ketones, magnesium, phosphate, lactate
Consider sodium bicarbonate if pH < 7 & myocardial dysfunction or vasodilation or life-threatening hyperkalemia
Complications
Cerebral edema
Pulmonary edema
Hyperthyroidism / Thyroid storm
Considerations
Optimization
Conflicts
Thyroid Storm
Hyperthyroidism / Thyroid storm
Considerations
Potential difficult airway if goitre present (airway compression, anterior mediastinal mass)
End organ effects of chronic hyperthyroidism:
Hypermetabolic state (↑ VO2, VCO2)
Cardiovascular: hypertension, tachycardia, myocardial ischemia, cardiomyopathy, arrhythmias
CNS: anxiety, psychiatric disorders
Muscle weakness
Risk of thyroid storm
Interactions with anesthetics:
↑ anesthetic requirements to control BP & HR. MAC requirement is NOT increased
Avoid sympathetic stimulants (ketamine, cocaine, epinephrine, etc)
Thyroidectomy:
Shared airway
Airway obstruction (tracheomalacia, recurrent laryngeal nerve injury, neck hematoma, hypocalcemia)
Optimization
Optimize thyroid function & limit end organ effects: heart rate <90, normal TSH
Identify difficult airway or anterior mediastinal mass
Identify & manage thyroid storm
Conflicts
Difficult airway/hemodynamic instability & sympathetic stimulants (cocaine, epinephrine, glycopyrrolate)
Hemodynamic instability & RSI
Thyroid storm
Emergency situation (mortality= 20%), consider endocrinology consult
IV fluids
Cool (blankets, IV solution, acetaminophen)
Control hemodynamics:
Esmolol 0.25-0.5 mg/kg bolus or 50-200 mcg/kg/min infusion
Propranolol 10-40 mg PO or up to 1 mg/min IV
Stop conversion of T4 to T3:
PTU 200-400 mg PO/NG/PR q6h
Hydrocortisone 100-200 mg IV q8h
Stop synthesis & release of new hormone:
Potassium iodide 5 gtts PO/NG q6h or sodium iodide 0.25 g IV q6h (1 hr after PTU)
Look for & treat complications:
CVA, loss of consciousness
Myocardial infarction, atrial fibrillation (avoid amiodarone because of iodide content; use digoxin instead) or congestive heart failure
Hypoventilation & hypercarbia
Electrolyte abnormalities
Consider differential diagnosis for hypermetabolic state
Consider last ditch treatments: plasmapheresis, dantrolene, lithium, neuraxial blockade to T4
Hyperparathyroidism
Background
Considerations
Optimization
Conflicts
Hyperparathyroidism
Background
Primary hyperparathyroidism: parathyroid adenoma or carcinoma
Secondary hyperparathyroidism: an appropriate compensatory response of the parathyroid glands to counteract a disease process that produces hypocalcemia
Ectopic hyperparathyroidism: due to secretion of parathyroid hormone (or a substance with similar endocrine effects) by tissues other than the parathyroid glands
Considerations
Potential difficult airway:
Mass effect (goitre)
Osteopenic bone (pathologic fractures of mandible & vertebral bodies)
Physiologic changes of hypercalcemia:
CNS: ↓LOC, hallucinations, psychosis
Cardiovascular: hypertension, hypovolemia, conduction blockade
Hypercalcemia ECG: ↑PR interval, ↓QTc
Respiratory: potential respiratory muscle weakness, poor clearance of secretions
Renal: renal failure, nephrolithiasis (70%)
GI: ↑ aspiration risk, nausea/vomiting, abdominal pain, pancreatitis
MSK: weakness (titrate neuromuscular blockers to effect), pathologic fractures (careful positioning)
Hematologic: anemia
Underlying etiology:
Parathyroid tumour, PTH-producing tumour
Chronic renal failure (usually associated with hypocalcemia, hyperphosphatemia)
Considerations of cancer & associated syndromes (MEN 1):
MEN 1: hyperparathyroid, pancreatic islet cell tumors, pituitary hyperplasia or tumor
MEN 2A: hyperparathyroid, medullary thyroid carcinoma, pheochromocytoma
Post-op airway obstruction after parathyroidectomy:
Hematoma, laryngospasm, hypocalcemia, recurrent laryngeal nerve injury, tracheomalacia
Mandibular fracture
Optimization
Management of hypercalcemia:
IV rehydration
Furosemide after IV hydration → goal is 3-5 L urine output/day
If severe, add:
Bisphosphonate (etidronate 7.5mg/kg IV OD or 20mg/kg PO OD)
Calcitonin 200 IU nasal spray/day
IV steroids
Phosphate repletion
Hemodialysis if life threatening hypercalcemia or acute renal failure
Monitor EKG & calcium concentrations perioperatively
Prevent pathological fractures (careful positioning)
Airway vigilance postoperatively
Conflicts
Hypovolemia vs. RSI (ESWL or percutaneous drainage for nephrolithiasis)
Renal failure vs. succinylcholine for RSI
