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ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7 295 © 2008 Elsevier Ltd. All rights reserved.
Endocrinology
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7 296 © 2008 Elsevier Ltd. All rights reserved.
Endocrinology
temporarily ischaemic. Diagnosis and management of this are advice of a specialist in calcium disorders is recommended, par-
described below. ticularly in relation to which patients are likely to respond to
pamidronate. This is because pamidronate is of value only if there
is documented excessive bone reabsorption.
Parathyroid surgery
Perioperative management is straightforward, bearing in
Parathyroidectomy is performed for hyperparathyroidism, in mind that these patients are frequently elderly, hypertensive
order to correct the resulting hypercalcaemia. Hypercalcaemia and slightly dehydrated. As with thyroid surgery, use of muscle
arises from excessive renal reabsorption and from excessive relaxation and intubation with a reinforced tube is usual. Dura-
osteoclast activity and bone resorption. Hyperparathyroidism tion of surgery varies from about 45 minutes in a straightforward
may be primary, that is, not following another condition, or sec- case with preoperative localization to 3–4 hours in a case with
ondary, most commonly in association with chronic renal failure. a difficult repeat procedure with several frozen-section samples
The first is usually attributable to a solitary adenoma, so requires required.
removal of a single gland, whereas the second is usually caused Postoperative pain is even less of a problem than it is with
by diffuse hyperplasia of the glands and requires removal of three thyroid surgery and the approach is the same.
or four glands. Tertiary hyperparathyroidism is also described, Clinically significant hypocalcaemia may follow parathy-
in which one of the hyperplastic glands in secondary disease roidectomy and is diagnosed by the presence of Chvostek’s and
becomes autonomous and undergoes adenomatous change. In Trousseau’s signs. Hypocalcaemia is more likely if there is sig-
primary disease, an attempt is made to identify the affected gland nificant bone disease because bone takes up calcium voraciously
preoperatively, either by ultrasound or by isotope scanning, or once the excess parathyroid stimulus is removed. Treatment is
both. This allows confident identification of the affected gland with slow intravenous calcium.
at surgery, so reducing operative time. Other imaging is not ne Parathyroidectomy under local anaesthetic has also been
cessary as the parathyroid gland does not distort the airway. In described and has achieved more popularity than thyroid surgery
secondary disease, preoperative scanning is rarely necessary as under local anaesthetic. It may be carried out with local infiltra-
the aim is to remove all four glands, and these are usually easily tion or cervical plexus blockade. This is done as a day case, in
identified at the time of surgery. those with clear preoperative localization, with the patients being
Specific preoperative issues are listed in Table 3. Occasionally, given calcium supplements to take at home to prevent hypocal-
there is severe hypercalcaemia which presents with confusion, caemia. Of course, it should also be possible to undertake this
electrolyte imbalance and dehydration. In these cases, surgery short surgery (less than 1 hour) under general anaesthesia as a
may be relatively urgent as the patient needs to remain in hos- day case, with appropriate discharge arrangements.
pital with intravenous fluids, frequent monitoring of electrolyte
levels, etc. Otherwise, the finding of elevated serum calcium lev-
Adrenalectomy for adrenocortical pathology
els should not cause anxiety for the anaesthetist. There is rarely a
clinical problem until the serum calcium concentration approaches Adrenalectomy may be carried out for Conn’s syndrome or Cush-
4 mmol/litre and medical treatment of hypercalcaemia before sur- ing’s syndrome. These causes of secondary hypertension occur
gery is necessary only if symptoms are present. Treatment then because of oversecretion of mineralocorticoid and glucocorticoid
comprises intravenous rehydration (up to 5–6 litres of isotonic respectively. Surgery is virtually always carried out laparoscopi-
saline in 24 hours), diuretics and sometimes pamidronate. The cally as the tumours themselves are small and easily extracted
through a small incision.
Clinical features of hyperparathyroidism of relevance Conn’s syndrome classically presents with hypertension and
to the anaesthetist hypokalaemia. Occasionally, there is glucose intolerance or meta
bolic alkalosis. The diagnosis is confirmed by the finding of ele-
• Hypertension There is an increased incidence of this condition vated hormone levels, often expressed as the aldosterone–renin
• Dehydration, often associated with polyuria and ratio. Sometimes, selective venous sampling with radiological
polydipsia The raised plasma calcium concentration impairs guidance is necessary. Preoperative treatment of hypertension
renal concentrating ability, so inappropriately dilute urine is should include potassium-retaining diuretics (e.g. spirono-
produced lactone) because profound postoperative hypokalaemia may
• Anaemia High concentrations of parathyroid hormone reduce otherwise occur.
the bone marrow response to erythropoietin (whether
intrinsic or given as a pharmacological agent). This can be Cushing’s syndrome may cause a multitude of preoperative
a particular problem in patients with chronic renal failure problems (Table 4). Frequently, all of these are present and
presenting with secondary hyperparathyroidism patients can present a major anaesthetic challenge, even after
• Depression, mood swings, sometimes progressing to overt the problems have been optimized. There should be a high index
psychosis of suspicion for Cushing’s syndrome when clinical features are
• Possible ECG changes (short Q–T interval), but overt present, but confirmation of the diagnosis is by the dexametha-
cardiovascular compromise (arrhythmias, cardiovascular sone suppression test. If this indicates Cushing’s syndrome,
collapse) is rare further tests are necessary to establish whether the problem is
a pituitary-dependent one or a primary adrenal one. Surgery is
Table 3 usually unilateral but may occasionally be bilateral.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7 297 © 2008 Elsevier Ltd. All rights reserved.
Endocrinology
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7 298 © 2008 Elsevier Ltd. All rights reserved.