Anesthetic considerations for patients with adrenal gland disorders.pptx

anaesthesia managments for adrenal disorders for non adrenal surgeries.

1. Anesthetic considerations for patients with adrenal gland disorders coming for non-endocrine surgery Mulat M. 9/20/2024 Department of Anaesthesia, BDU 1

2. Session outline Objectives Hypothalamic-Pituitary-Adrenal Disorders Causes of excess adrenal hormone Anesthesia’s challenges patients with Cushing syndrome Adrenal Insufficiency References 9/20/2024 Department of Anaesthesia, BDU 2

3. Objectives At the end of this session the students be able to:- Identify the types of adrenal disorders Determine the preoperative plan for patients with adrenal disorder Manage intraoperative anesthesia Involve post operative recovery follow up for patients with adrenal disorders 9/20/2024 Department of Anaesthesia, BDU 3

4. Hypothalamic-Pituitary-Adrenal Disorders The hypothalamus releases corticotropin -releasing hormone(CRH) Which regulates adrenocorticotropic hormone (ACTH) release from the anterior pituitary gland. ACTH , in turn, regulates cortisol release from the adrenal cortex. . 9/20/2024 Department of Anaesthesia, BDU 4

5. Hypothalamic-Pituitary-Adrenal Disorders… Cortisol secretion varies with the circadian rhythm , with the highest release in the morning. Additionally, release increases with physical stress, psychological stress, fever, and hypoglycemia. Among physical stressors, surgery is one of the most potent activators of the hypothalamic-pituitary-adrenal axis 9/20/2024 Department of Anaesthesia, BDU 5

6. Hypothalamic-Pituitary-Adrenal Disorders… Although ACTH concentrations increase with surgical incision and through the surgical procedure, The greatest ACTH secretion occurs during termination of anesthesia and the immediate postoperative period . The magnitude and duration of the cortisol response reflects the degree of physiological stress imposed by the surgical stress. 9/20/2024 Department of Anaesthesia, BDU 6

7. Hypothalamic-Pituitary-Adrenal Disorders… In procedures with minimal associated stress (e.g., inguinal hernia repair), increased cortisol secretion lasts for about 24 hours. In more complicated procedures (e.g., major abdominal surgery), the response is larger in magnitude and lasts for about 5 days after surgery. 9/20/2024 Department of Anaesthesia, BDU 7

8. Why excess adrenal hormone? Excess adrenal hormones result from endogenous cortisol associated with pituitary or adrenal tumors, exogenous glucocorticoids used to treat disorders such as asthma or inflammatory diseases Cushing syndrome refers to the combinations and symptoms due to chronic excess glucocorticoid exposure (either endogenous or exogenous). 9/20/2024 Department of Anaesthesia, BDU 8

9. Why excess adrenal hormone?... Cushing disease is the specific situation when the excess glucocorticoids are related to an ACTH-producing pituitary tumor Other causes of Cushing syndrome include exogenous corticosteroids, adrenal tumors, adrenal hyperplasia, and neoplasms that secrete ectopic ACTH. 9/20/2024 Department of Anaesthesia, BDU 9

10. Why excess adrenal hormone?... The major manifestations of Cushing syndrome are obesity (with characteristic patterns of fat deposition causing “moon facies ” and a “buffalo hump”), diabetes mellitus, female virilization , OSA, hypertension, elevated cardiovascular risk, elevated venous thromboembolism (VTE) risk, osteoporosis, striae , skin atrophy, and easy bruising . 9/20/2024 Department of Anaesthesia, BDU 10

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12. What are the challenges Cushing syndrome? Airway management can be challenging in affected patients due to obesity and OSA In addition, peripheral intravenous access can be difficult because of skin atrophy and obesity . These patients may require an ECG and blood sampling for electrolytes and glucose. Despite easy bruising, they have normal coagulation profiles. 9/20/2024 Department of Anaesthesia, BDU 12

13. What are the challenges Cushing syndrome ?... Chronic corticosteroid exposure is whether perioperative “stress-dose steroids” are needed. Both endogenous and exogenous glucocorticoids exert important negative feedback suppression on the hypothalamic-pituitary-adrenal axis. Thus, chronic exogenous corticosteroid exposure suppresses the adrenals And may blunt the normal cortisol hyper-secretion associated with surgery—even if the patient does not demonstrate Cushing syndrome. 9/20/2024 Department of Anaesthesia, BDU 13

14. What are the challenges Cushing syndrome?... Perioperative corticosteroid supplementation is needed only when a patient is likely to have suppression of the hypothalamic-pituitary-adrenal axis. Thus, supplementation is not required for individuals who have received less than 5 mg prednisone (or its equivalent) daily, or less than 3 weeks of corticosteroids (regardless of dose). 9/20/2024 Department of Anaesthesia, BDU 14

15. What are the challenges Cushing syndrome?... These individuals should simply continue their usual long-term corticosteroid regimen through the perioperative period. Conversely, patients taking prednisone (or its equivalent) In daily doses exceeding 20 mg/day for more than 3 weeks, And patients with Cushing syndrome should have perioperative corticosteroid supplementation 9/20/2024 Department of Anaesthesia, BDU 15

16. What are the challenges Cushing syndrome?... The need for supplementation is unclear for patients Who have taken prednisone (or its equivalent) at a daily dose of 5 to 20 mg for more than 3 weeks. The options are to simply empirically Provide perioperative corticosteroid supplementation or refer the patient to an endocrinologist for formal evaluation of their hypothalamic-pituitary-adrenal axis. 9/20/2024 Department of Anaesthesia, BDU 16

17. What are the challenges Cushing syndrome?... There is no clear consensus on the optimal perioperative corticosteroid supplementation regimen. A proposed regimen that accounts for contemporary evidence and different stress-response profiles across surgical procedures is presented in Table 31.15. 9/20/2024 Department of Anaesthesia, BDU 17

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19. Adrenal Insufficiency( Addison’s disease) Patients with adrenal insufficiency have weakness , weight loss, hypotension, orthostasis , hypovolemia , hyperpigmentation, and electrolyte abnormalities. Adrenal insufficiency results from destruction of the pituitary gland, destruction of the adrenal glands ( e.g., autoimmune disease, tuberculosis, HIV infection), or long-term exogenous glucocorticoid administration (most common cause). 9/20/2024 Department of Anaesthesia, BDU 19

20. Adrenal Insufficiency… To help establish the diagnosis and cause of adrenal insufficiency, patients require a morning cortisol concentration measurement, morning plasma ACTH concentration measurement, and often an ACTH stimulation test. If the serum cortisol concentration is inappropriately low and a simultaneous plasma ACTH concentration is very high, primary adrenal insufficiency (i.e., primary adrenal disease) is the cause 9/20/2024 Department of Anaesthesia, BDU 20

21. Adrenal Insufficiency… if both serum cortisol and plasma ACTH concentrations are inappropriately low. Secondary (i.e., pituitary disease) or tertiary (i.e., hypothalamic disease) is the diagnosis Consultation with an endocrinologist is required if formal diagnostic testing for adrenal insufficiency is required, and to facilitate treatment of patients meeting the diagnostic criteria. 9/20/2024 Department of Anaesthesia, BDU 21

22. Adrenal Insufficiency… Patients should continue their replacement corticosteroid therapy on the day of surgery And may need further supplementation based on the expected surgical stress response Importantly, aldosterone , although also produced by the adrenal cortex, is controlled instead by the renin-angiotensin system , not the hypothalamic-pituitary-adrenal axis. Aldosterone regulates volume and electrolytes (absorption of sodium and chloride; secretion of potassium and hydrogen ions). 9/20/2024 Department of Anaesthesia, BDU 22

23. References Miller’s anaesthesia , 9 th ed Barash Clinical Anaesthesia , 8 th ed Handbook of clinical anesthesia. 7 th ed 9/20/2024 Department of Anaesthesia, BDU 23