What are the perioperative and postoperative management strategies for patients with endocrine pathologies undergoing surgery?

Perioperative and Postoperative Management of Endocrine Pathologies

Patients with endocrine disorders require specific perioperative and postoperative management strategies to prevent morbidity and mortality, with glucocorticoid supplementation being essential for those with adrenal insufficiency and careful monitoring of fluid and electrolyte balance for those with pituitary disorders.

Adrenal Insufficiency Management

Preoperative Assessment

• Identify patients at risk: those with known adrenal insufficiency, on chronic steroid therapy (prednisolone ≥5mg for >4 weeks), or with pituitary disorders affecting the HPA axis
• Collaborate with patient's endocrinologist when planning scheduled surgery 1
• Review patient's history of glucocorticoid self-management and previous episodes of adrenal crisis 1

Perioperative Glucocorticoid Management

For adults with adrenal insufficiency:

1. Intraoperative management:

   • Administer hydrocortisone 100mg IV at induction of anesthesia
   • Immediately initiate continuous infusion of hydrocortisone 200mg/24h 1

2. Postoperative management:

   • Continue hydrocortisone 200mg/24h by IV infusion while nil by mouth
   • Alternative: hydrocortisone 50mg every 6h by IM injection if IV infusion impractical
   • Once oral intake resumes, double usual oral glucocorticoid dose for 48h or up to a week following major surgery 1

3. Special considerations:

   • For pregnant patients with adrenal insufficiency: higher maintenance dose during later pregnancy (after 20 weeks)
   • During labor: hydrocortisone 100mg at onset, followed by continuous IV infusion of 200mg/24h or 50mg IM every 6h until after delivery 1

Monitoring for Adrenal Crisis

Watch for early signs of adrenal crisis:

• Non-specific malaise, somnolence, cognitive dysfunction
• Nausea, vomiting, abdominal pain
• Hypotension (late sign)
• Hypoglycemia, hyponatremia, hyperkalemia 1

Thyroid Disorders Management

Hypothyroidism

• Mild hypothyroidism: can safely proceed with elective surgery
• Moderate/severe hypothyroidism: postpone elective surgery until euthyroid 2
• Ensure proper levothyroxine administration: single dose on empty stomach, half to one hour before breakfast 3
• Avoid administering levothyroxine within 4 hours of iron, calcium supplements, or antacids 3

Hyperthyroidism

• Mild hyperthyroidism: can undergo elective surgery with preoperative beta blockade
• Moderate/severe hyperthyroidism: postpone elective surgery until euthyroid 2

Post-Thyroidectomy Care

• Monitor for neck hematoma formation (incidence 0.45-4.2%) 1
• Highest risk period: first 24 hours, with approximately half occurring within 6 hours 1
• Watch for signs of airway compromise: progressive neck swelling, respiratory distress, stridor
• Have emergency equipment readily available for potential bedside hematoma evacuation 1

Pituitary Disorders Management

Diabetes Insipidus After Pituitary Surgery

• Incidence: approximately 26% of patients postoperatively 4
• Risk factors: female sex, CSF leak, surgical drain placement, manipulation of posterior pituitary 4

Monitoring and Diagnosis

• Strict fluid and electrolyte monitoring with careful tracking of input/output
• Watch for high urine output, increased serum sodium, excessive thirst within first 24-48 hours 4

Treatment

• For confirmed diabetes insipidus with serum sodium >145 mmol/L and high urine output:
  • Desmopressin nasal spray 0.01% (initial dose: 5-10 μg intranasally)
  • Alternative: desmopressin injection when nasal route compromised
  • Monitor for triphasic response with daily electrolytes 4

Water Metabolism Changes After Pituitary Surgery

• Several patterns may occur:
  1. Transient or permanent AVP deficiency
  2. Biphasic response: AVP deficiency followed by SIADH
  3. Triphasic pattern with usually permanent AVP deficiency 1
• Close observation required with careful monitoring of fluid input and output 1

General Perioperative Considerations

Diabetes Mellitus

• Perioperative management based on:
  • Type of diabetes
  • Current medications
  • Glycemic control status
  • Type of surgery planned
• Bedside glucose monitoring essential 2

Pheochromocytoma

• Must be identified and properly treated before surgery to prevent perioperative cardiovascular complications 2
• Careful preoperative alpha-blockade followed by beta-blockade as needed

Common Pitfalls to Avoid

1. For adrenal insufficiency:

   • Inadequate glucocorticoid dosing during surgical stress
   • Failure to recognize early signs of adrenal crisis
   • Abrupt discontinuation of steroids postoperatively

2. For diabetes insipidus:

   • Missing the triphasic response
   • Inadequate monitoring of fluid status and electrolytes
   • Overtreatment or undertreatment 4

3. For thyroid disorders:

   • Failure to recognize neck hematoma after thyroid surgery
   • Delayed intervention for airway compromise
   • Inadequate monitoring in first 24 hours post-thyroidectomy 1

Remember that optimizing endocrine function before surgery whenever possible is crucial for reducing perioperative morbidity and mortality. When endocrine emergencies occur, prompt recognition and management are essential.