Anesthesia for Endocrine Emergencies

Progress in surgical approaches and outcomes of patients with pheochromocytoma and paraganglioma

Significant advances have been made in the past few decades in surgical management and outcomes of patients with pheochromocytoma and paraganglioma. Improvements in preoperative hypertensive control with the implementation of alpha- and beta-adrenergic blockade has resulted in better intra-operative blood pressure control and less incidence of hypertensive crises, which had been a large source of morbidity in the past. Emphasis on anesthesia and surgical team communication has also assisted in minimizing intraoperative hypertensive events at critical points of the operation. Shifting away from open resection, the now standard-of-care laparoscopic and minimally invasive adrenalectomy offers less pain, shorter hospitalizations, and quicker recoveries. Patient underlying germline mutations can guide the timing, approach, and extent of surgery. Postoperative outcomes have significantly improved with recent advancements in perioperative care in addition to regimented biochemical and radiographic surveillance. Here, we highlight the recent advancements in surgical approaches and outcomes for patients with pheochromocytoma and paraganglioma.

Perioperative Blood Pressure Management Recommendations in Pediatric Pheochromocytoma: A 10-Year Narrative Review

BACKGROUND

Pheochromocytomas and paragangliomas are rare chromaffin cell-derived tumors characterized by catecholamine-secreting activity. Pheochromocytomas account for 1.7% of pediatric hypertension cases. Surgical resection, the definitive pheochromocytoma treatment, carries risks of hemodynamic instability and cardiovascular complications. Nevertheless, mortality rates decreased significantly in the latter half of the 20th century due to effective perioperative blood pressure (BP) management. The literature on BP management tailored to pediatric pheochromocytoma is limited, while the sustained hypertension rate in this population is high (up to 90%) and related to a high risk of intraoperative complications. In this narrative review, we provide up-to-date recommendations regarding BP management to minimize perioperative comorbidities in children with pheochromocytoma.

SUMMARY

Antihypertensive agents, primarily alpha (α)-blockers, should be promptly administered for suspected pheochromocytoma. Beta (β)-blockers may be introduced thereafter to counteract reflex tachycardia. The patient must be salt- and water-replete preoperation. Intraoperatively, stable hemodynamics should be ensured during anesthesia and surgery, and short-acting intravenous medications and resuscitation fluid should be supplied. Postoperatively, patients should be admitted to the pediatric intensive care unit for close monitoring for at least 24-48 h. Genetic testing is recommended for all pheochromocytoma patients. Identifying underlying mutations, like in succinate dehydrogenase subunit B, which is linked to a higher risk of multifocality and metastasis, is imperative for tailoring treatment strategies and prognostication.

KEY MESSAGES

Achieving optimal outcomes in pediatric pheochromocytoma relies on preoperative BP optimization with appropriate antihypertensive agents, intraoperative hemodynamic stability, and postoperative routine long-term follow-up to monitor for complications, recurrence, and metastasis. Future research should prioritize well-designed prospective multicenter studies with adequate sample sizes and, where feasible, randomized controlled trials with standardized protocols and appropriate endpoints. These studies should focus on the efficacy and safety of preoperative nonselective versus selective α-blockers, whether as monotherapy or combined with other medications (e.g., calcium channel blockers and/or β-blockers), or treatment without preoperative anti-hypertensives.

Anesthetic Management of Emergency Insulinoma Resection: Case Report and Review of Literature

Insulinoma, a neuroendocrine tumor originating from pancreatic islets, presents unique challenges in diagnosis and management. We present a case of a 73-year-old female with recurrent hypoglycemia leading to syncope, who underwent emergency pancreatectomy for a secreting insulinoma with multiple comorbidities. This case report aims to shed light on the complexities of insulinoma management and the importance of tailored perioperative strategies. The patient, presenting with severe hypoglycemia, was admitted for optimization. Preoperative assessment labeled her as ASA IVE and indicated a high risk of perioperative morbidity. General anesthesia, invasive monitoring, and epidural anesthesia were planned. Intraoperative glucose control was crucial, achieved with continuous blood glucose monitoring, octreotide administration, and insulin titration. The patient was extubated post-surgery, and pain was managed with epidural infusion. She was discharged on the 4th postoperative day with follow-up care. Insulinoma diagnosis relies on clinical, biochemical, and imaging tests, with 72-hour fasting as the gold standard. Localizing the tumor within the pancreas is essential for surgical success, often requiring invasive techniques. Surgical resection remains the definitive treatment, while medical management may be necessary in select cases. Anesthetic management should prioritize agents that minimize the cerebral metabolic rate for oxygen. Careful intraoperative glucose control and vigilant postoperative monitoring are essential. This case report highlights the intricate management of insulinoma, emphasizing tailored perioperative strategies that balance glucose regulation, anesthesia techniques, and postoperative care. However, the limited existing literature underscores the need for further research to refine anesthesia protocols, glucose control methods, and postoperative care, ultimately improving outcomes for patients with insulinoma.

Molar Pregnancy-Induced Hyperthyroidism: The Importance of Early Recognition and Timely Preoperative Management

Hyperthyroidism due to gestational trophoblastic disease (GTD) is a rare but potentially life-threatening condition. Optimal perioperative management is crucial for favorable outcomes and prevention of thyroid storm. However, scarce data exist defining the ideal approach to this complex clinical presentation. This case report describes a first-time pregnant 32-year-old woman who was found to be biochemically hyperthyroid in the context of a 10-week gestation molar pregnancy. Despite her biochemical values, the patient remained clinically asymptomatic of her thyroid disease. The Gynecology and Anesthesiology services urgently consulted Endocrinology, and empiric treatment for prevention of potential impending thyroid storm was initiated prior to operative uterine evacuation. After 2 uneventful dilation and curettages with chemotherapy and a transient prescription of antithyroid medication, the patient normalized her human chorionic gonadotropin (hCG) level and recovered to biochemical euthyroidism. Other than a pruritic rash that may have been due to propylthiouracil, the patient's hyperthyroidism improved without further complications. This case highlights the importance of recognizing the link between GTD and thyrotoxicosis to allow for timely initiation of appropriate preoperative treatment. Fortunately, the multidisciplinary approach facilitated management to prevent evolution to thyroid storm.

Anesthetic Management of Laparoscopic Adrenalectomy for a Patient with Concomitant Pheochromocytoma and Bilateral Carotid Artery Stenosis

Symptomatic carotid stenosis and pheochromocytoma both require timely surgical intervention. Following a transient ischemic attack (TIA), a 46-year-old man was diagnosed with bilateral carotid artery stenosis and scheduled for carotid endarterectomy. He was a poor candidate for minimally invasive options due to prior neck radiation. Simultaneously, he began experiencing difficulty with diabetes management and elevated blood pressures and was ultimately diagnosed with pheochromocytoma. This unique situation required coordination to determine the appropriate timing of the two interventions. This case highlights the importance of communication and coordination amongst medical specialists and consideration for anesthetic management of patients with concomitant pheochromocytoma and carotid stenosis.

Anesthetic management of a giant paraganglioma resection: a case report

BACKGROUND

Patients with pheochromocytomas are often diagnosed with acute myocardial infarction (AMI) due to initial symptoms of palpitations and chest tightness. We describe a case of AMI syndrome where a giant paraganglioma was unexpectedly identified. The anesthetic management of the paraganglioma resection was challenging and complex.

CASE PRESENTATION

A 66-year-old woman was admitted to the emergency department for complaints of palpitations, chest tightness and vomiting. A laboratory test revealed that troponin I and N-terminal pro-brain natriuretic peptide levels were dramatically increased. Emergency percutaneous coronary angiography (CAG) showed normal coronary arteries. In addition, the serum levels of free catecholamines were increased, and computed tomography and magnetic resonance imaging revealed a heterogenous mass lesion in the right retroperitoneal. All of this ultimately confirmed the diagnosis of pheochromocytoma. After three weeks of careful preoperative preparation by a multidisciplinary team, and an anesthesiologist team develops detailed perianesthesia management strategies to maintain hemodynamics and blood glucose stability and regulate acid-base balance, pheochromocytoma resection was performed successfully. About 2 weeks later, the patient was discharged healthy. A postoperative pathology test confirmed paraganglioma.

CONCLUSIONS

To our knowledge, giant pheochromocytoma resection is a complex challenge for the anesthesiologists, this clinical case may supply a thoughtful experience for anesthetic management in the resection of giant pheochromocytomas. Adequate preoperative evaluation and prudent perianesthesia management by anesthesiologists are important guarantees for patients to obtain a good prognosis and discharge healthily.

Effect of Continuous Subcutaneous Injection of Insulin Analogues in Pregnant Women with Diabetes Mellitus Complicated with Ketoacidosis

OBJECTIVE

To investigate the clinical effect of continuous subcutaneous injection of insulin analogues in pregnant women with diabetes mellitus complicated with ketoacidosis.

METHODS

A total of 92 pregnant patients with diabetes mellitus complicated with ketoacidosis from June 2014 to January 2021 were selected. All patients were randomly divided into an observation group and control group according to the method of random number. The control group received intravenous infusion of insulin, and the observation group received continuous subcutaneous infusion of quick-acting insulin analogues. The clinical effects of the two groups were observed.

RESULTS

The time needed to control blood glucose <13.8 mmol/L, the amount of insulin needed to control blood glucose <13.8 mmol/L, the time needed to correct DKA, and the amount of insulin needed to correct DKA in the observation group were significantly less than those in the control group (P < 0.05). Compared with the control group, the average occurrence times of hypoglycemia, the length of stay, the total amount of insulin in hospital, and the total amount of insulin used during pregnancy in the observation group were significantly less than those in the control group (P < 0.05). The values of SCr, CRP, BUN, arterial blood gas pH, and adiponectin in the two groups were significantly improved as compared with those before treatment, and the improvement in the observation group was significantly better than that in the control group (P < 0.05). After treatment, the fasting blood glucose, 2-hour postprandial blood glucose, carbon dioxide binding capacity, and glycosylated hemoglobin in the experimental group were significantly better than those in the routine group, and the difference was statistically significant (P < 0.05).

CONCLUSION

Continuous subcutaneous injection of insulin analogues is effective in the treatment of diabetic patients with ketoacidosis, which can effectively improve blood glucose, carbon dioxide binding capacity, and glycosylated hemoglobin and accelerate the negative conversion of urinary ketone body. It is worth popularizing to reduce the occurrence of hypoglycemia and the dose of insulin and shorten the time of hospitalization.

When Zebras Collide: A Case of Synchronous Wolff-Parkinson-White Syndrome and Pheochromocytoma

Patient: Male, 36-year-old

Final Diagnosis: Pheochromocytoma

Symptoms: Chest discomfort • headache • shortness of breath • symptomatic tachyarrhythmia

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

OBJECTIVE

To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs).

METHODS

This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center.

RESULTS

Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications.

CONCLUSIONS

An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

Endocrine emergencies in anesthesia

PURPOSE OF REVIEW

An increasing number of patients with endocrine disorders will present to the operating rooms. In this review, we outline the common endocrine disorders that the anesthesiologist may face in the perioperative time span, review the controversies in optimal management, as well as summarize the recent literature for the management of these complex patients.

RECENT FINDINGS

Perioperative management of pheochromocytoma and paraganglioma has been facilitated by improved medical management and the adoption of minimally invasive surgical techniques. An improved understanding of the sequelae of carcinoid syndrome has resulted in safer perioperative management. Perioperative glycemic management requires a fundamental understanding of perioperative fluid resuscitation and adverse events associated with the new generation oral hyperglycemic agents to prevent avoidable complications.

SUMMARY

Endocrine disorders will commonly present in the perioperative time period and the anesthesiologist plays a critical role in achieving good operative outcomes.