Endocrinology - surgical patient management Flashcards
what is the thyroid made up of?
▪ Paired bilobed gland
▪ Larynx
▪ Trachea
▪ Blood vessels
▪ Nerves
▪ Ectopic tissue
what are benign surgical conditions of the thyroid?
- Adenoma
- Adenomatous Hyperplasia
- Cysts
what is a functional surgical condition??
producing throid hormones
what type of mass are benign masses in cats?
functional
which masses are typically non-functional?
benign masses in dogs
what can functionalthyroid masses in cats cause?
hyperthyroidism
what malignant neoplasia can occur in the thyroid?
- Carcinoma
- Adenocarcinoma
what pre-operative thryoidectomy considerations are there of the cat?
*ASA status
* Systemic effects of hyperthyroidism
* Body condition score - weight loss, muscle loss
* Metastasis?
* Cardiovascular - tachycardia, hypertension
* Renal - pre-renal azotaemia
* Ocular - retinal detachment
* Co-morbidities unrelated to hyperthyroidism - CV, renal, increased anaesthetic risk, cachexia, arthritis
* Medical stabilisation
* Complications
what are the pre-operative considerations for thyroidectomy in the dog?
- Far fewer systemic effects as non-functional
- Body condition score: may be reduced due to effects of the cancer
- Metastasis? Hopefully we’ve ruled this out pre-op
- Up to 40% dogs have mets at presentation
- Co-morbidities often present as typically older animals
*Medical stabilisation - Pre-op not needed as non-functional
- Post-op requirement will depend on surgery e.g. unilateral vs bilateral
how should you prep for a thyroidectomy?
- Wide ventral neck clip and from level of jaw to thoracic inlet
- Patient position in dorsal recumbency with sandbag etc under neck to elevate.
- Keep neck straight
what are complications that can arise form a thyroidectomy?
- Haemorrhage
- Seroma formation
- Laryngeal paralysis
- Horners
- Hypocalcaemia
- Recurrence
what pre-emptive peri-operative support can you provide during thyroidectomy?
vpre-op vitamin d or post-op oral calcium
what does parathyroid hormone do?
increase blood calcium
how many parathyroid glands are there and what are they?
4
* Left extracapsular (cranial)
* Right extracapsular
* Left intracapsular (caudal)
* Right intracapsular
what medical treatment can be done for primary hyperthyroidism?
▪ Ethanol injection
▪ Heat ablation
what surgical treatment can you do for primary hyperthyroidism?
parathyroidectomy
what post-operative treatment can you do for primary hyperthyroidism?
monitor for hypoglycaemmia
what pre-operative considerations are there for parathyroidectomy?
*Systemic effects
* Hypercalcaemia
* Affects renal function
* Co-morbidities as typically older animals
Medical stabilisation to improve ASA status
* Diuresis with high levels of IVFT to ‘dilute’ the calcium?
* Support renal function
what are the complciations of parathyroidectomy?
- Haemorrhage
- Seroma formation - depends on size of mass
- Laryngeal paralysis
- Horners
- Hypocalcaemia
*hypothyroidism
what post-op care would you provide after a parathyroidectomy?
*IVFT
* Standard care according to clinical appearance and losses
Analgesia
* Avoid NSAIDs
Monitor for complications
* Renal function
* Calcium => More shortly
Prognosis
* Usually good
* Hypocalcaemia can be transient (days) , or can take weeks / months to recover
what are the clinical signs associated with iatrogenic hypoparathyroidisms?
- Initially
- Inappetence
- Weakness / Lethargy
- Ptyalism
- Pawing at face
- More advanced
- Tremors
- Tetany
- Seizures, coma and death
how can you monitor for hypoglycaemia after parathyroidectomy?
- Vitamin D
- Monitor blood calcium
- Monitor clinical signs
- Calcium administration
how would you treat hypoglycaemia after parathyroidectomy?
- oral Vitamin D which takes 24-48hrs to effect
- Oral calcium - home with patient
- Intravenous 10% calcium gluconate
what should you monitor after giving Intravenous 10% calcium gluconate slowly (10-20 mins)?
*Monitor with an ECG for arrhythmia and bradycardia
* Initial bolus followed by constant rate intravenous infusion
* Avoid bicarbonate, lactate or phosphate containing fluids → precipitate calcium
what common pancreatic conditions are there?
diabetes and pancreatitis
what are more uncommon pancreatic conditions?
insulinoma, exocrine pancreatic neoplasia, pancreatic abscessation and pancreatic cysts
what are the clinical signs of insulinoma?
lethargy, tremors, seizures, collapse, peripheral neuropathy due to hypoglycaemia
what pre-oeprative management can you do for insulinoma?
- feed every 4-6hrs
- diabetic diet
- pre-op starvation?
- gentle regular exercise
- manage hypoglycaemia
what should you do if a aptient is having a hypoglycaemic crisis?
- give oral glucose or anything sugary
- one off IV glucose 0.5-1mL/kg of 50% dextrose diluted
- glucose infusion 2.5% solution
what post op management can you do for insulinoma?
- feeding +/- feeding tube
- manage hypoglycaemia
- exercise plan
- drugs (analgesia, steroids, octreotide, chemo
what complications can arise after insulinoma surgery?
- Persistence of hypoglycaemia
- Transient Hyperglycaemia
- Pancreatitis
- Can develop Diabetes Mellitus
what is internal adrenal anatomy?
outer cortex and inner medulla
what types of adrenal masses are there?
benign/malignant masses and primary or secondary tumours
what secondaryadrenal gland conditions are there?
adrenal enlargement (pituitary)
if there are no clinical signs with adrenal gland disease what is this?
incidentaloma
what functional clincial signs are there of adrenal gland disease?
- overproduction from cortex *Cushing’s, conns syndrome, mineralcortoicoid, glucocorticoid, masculinising sydrome, androgen
- overproduction from the medulla production from medulla
- Phaeochromocytoma / Catecholamines e.g. Norepinephrine and/or Epinephrine => intermittent
hypertension
what are benign adrenal glands enlargements usually?
adenomas
what are malignant adrenal gland enlargements?
adenocarcinoma
what can phaeochromactomas be?
malignant or benign
what systemic effects are there from adrenalectomy?
*Conns Syndrome => hypokalaemia
* Cushings Syndrome => endogenous steroid => poor surgical candidate
* Phaeochromocytoma => excess adrenaline/noradrenaline => unstable patient
what can you do to stabilise a patient to improve ASA status?
*Manage potassium => Potassium supplementation
* Stabilise with medication e.g. Trilostane
* Phaeo – stabilise with medication e.g. Phenoxybenzamine for 2-3 weeks pre-op (alpha adrenergic blocker)
how can you manage a patient post-operatively after adrenalectomy?
- cardiovascular function (ECGs and blood pressure)
- electrolytes
what post op complications can occur after arenalectomy?
- Electrolyte abnormalities
- Hypertension / Hypotension
- Adrenal insufficiency requiring supplementation like an iatrogenic Addisons > mineralocorticoids and
glucocorticoids - Delayed healing
- Pulmonary thromboembolism
what intra-operative complications can occur during adrenalectomy?
*Tumour rupture
* Haemorrhage
* Tachycardia / cardiac arrhythmias
* May need drugs to stabilise e.g. propranolol / lignocaine
* Hypertension / Hypotension
* May need supplementation of gluco- and mineralo-corticoids during surgery (Dexamethasone and Electrolytes (sodium and potassium))
