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Ch36. Anesthesia for Patients with Endocrine Disease

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  1. Ch36. Anesthesia for Patients with Endocrine Disease R 1 임형우

  2. THE PANCREAS • 매일 insulin 50U 분비 • Insulin • Most important anabolic hormone • Adipose & muscle cell로의 glucose와 potassium entry 증대

  3. D.M Clinical manifestation(1) • DM : impairment of carbohydrate metabolism • Caused by absolute or relative eficiency of insulin or insulin responsiveness • Dx • Fasting plasma glucose > 140mg/dL • Blood glucose > 126mg/dL

  4. Clinical manifestation (2) • Long-term complications • HTN • Coronary artery disease • MI • CHF • Diastolic dysfunction • Peripheral & cerebral vascular disease • Peripheral & autonomic neuropathies • Renal failure • Three life-threatening acute complications • DKA (diabetic ketoacidosis) • Hyperosmolar nonketotic coma • hypoglycemia

  5. Clinical manifestation (3) • DKA • Insulin activity 감소로 free fatty acid의 ketone body로의 catabolism 증가하여 anion gap metabolic acidosis 발생 • DDx : Lactic acidosis • 1. Plasma lactate 증가 (>6mmol/L) • 2. Urine & plasma ketone이 없음 • Infection : m/c cause • 증상 : tachypnea, abd. pain, N/V, changes in sensorium • 치료 • Hypovolemia, hyperglycemia, total body potassium deficit 교정 • Isotonic fluids & potassium, insulin infusion • 혈당 강하는 75-100 mg/dL/h or 10%/h 속도로 • 대개 insulin 치료는 0.1U/kg/h iv or (blood glucose – 60) * 0.1 U/h로 시작 • Potassium, blood glucose, serum ketones : 최소 2시간마다 측정 • Dehydration 교정 위해 NS 다량 필요 (첫 1시간에 1-2L, 그 후 200-500mL/h) • Lactated Ringer’s solution 금기 • 혈당이 250mg/dL까지 떨어지면 insulin에 D5W 추가 • Nasogastric tube (for gastric decompression), bladder catheterization (urine output monitor)

  6. Clinical manifestation (4) • Hyperosmolar nonketotic coma: DKA처럼 인슐린이 적지않아 케톤바디 형성 없음 • Hyperglycemic diuresis로 dehydration, hyperosmolality 발생 ->Renal failure, lactic acidosis, intravascular thromboses 초래 • Hyperosmolality (>360mOsm/L) • Severe hyperglycemia는 hyponatremia 유발 • 치료 • Fluid (NS), insulin (relatively small dose), potassium 투여 • Hypoglycemia (혈당 < 50mg/dL) • Carbohydrate intake에 비해 insulin 과다로 발생 • Brain은 glucose만을 사용하므로 저혈당에 취약 • 증상 • 의식 변화 • Lightheadedness, confusion ~ confusion, permanent coma • 전신 증상 : catecholamine 분비로 인함 • (Diaphoresis, tachycardia, nervousness) • 치료 • 50% glucose iv • (50% glucose 1ml는 70kg pt에서 blood glucose 2mg/dL 증가시킴)

  7. Anesthetic considerationsA. preoperative • HbA1c 높을 경우 Cx 증가 • Periop. Morbidity와 관련 • Pulm., cardiovascular, renal system 주의 필요 • CXR : cardiac enlargement, pulm. vascular congestion, pleural effusion 확인 • ECG : ST-, T-segment abnl 흔함 • Diabetic autonomic neuropathy • HTN 함께 있을 경우 50%에서 존재 • Intravascular volume 변화에 대한 심장의 보상능력 제한됨 • Cardiovascular instability ->(postinduction hypotension) • Sudden cardiac death –> ACE inhibitor 사용시 증가 • ANS의 refelx dysfunction 증가 요인들 • (Old age, 10년 이상된 DM, coronary a. disease, β-adrenergic blockade • Delayed gastric emptying • Premedi시 antacid, metoclopramide 사용 • Limited-mobility joint syndrome • Chronic hyperglycemia로 tissue prot.의 glycosylation 발생 • (DM 환자에서는 항상 적절한 temporomandibular joint와 c-spine의 mobility를 확인하여야 함 Type I DM 의 30%에서 difficult intubation)

  8. B. intraoperative(1) • Primary goal : hypoglycemia 방지 Hyperglycemia -> hyperosmolarity, infection, poor wound healing 가져옴 ->Cerebral ischemia후 neurological outcome 악화시키고, AMI나 cardiac surgery의 예후 나쁘게 함

  9. B. intraoperative (2) • Periop. Management regimens • Total morning intermediate-acting insulin dose의 일부(대개 절반) 투여 • D5W (1.5mL/kg/h) 함께 투여 • Intraop. hyperglycemia(150-180mg/dL)는 iv RI sliding scale로 조절 (성인에서 RI 1U는 plasma glucose 25-30mg/dL 감소시킴) • RI continuous infusion • RI 250U를 NS 250mL에 섞어 0.1U/kg/h로 시작 • General target • Blood glucose 120-150mg/dL • Fluid 1L마다 KCl 20mEq 섞어 insulin에 의한 intracellular potassium shift에 대비

  10. B. intraoperative (3) • Oral hypoglycemic agent 사용 중일 경우 수술 당일까지 지속 가능 • Sulfonylurea & metformin은 수술 24-48h 전부터는 사용 금지 (Long half-lives 때문) • Stress hyperglycemia • Stress of surgery 때문에 counteregulatory hormones 증가하고 infl. mediator 분비되어 발생 • Monitor plasma glucose level • Type I DM은 매시간마다, type II DM은 2-3시간마다 • 아침에 insulin 투여 후 오후에 수술 받을 경우 hypoglycemia 위험 • Portable spectrophotometers • NPH or protamine zinc insulin • Protamine sulfate에 대한 allergic reaction risk 높아짐 • Protamine 투여 필요 시 full reversal dose에 앞서 test dose (1-5mg) 먼저 투여

  11. C. postoperative • Close monitoring of blood sugar해야함 1.Insulin preparation에 따라 작용시간이 다르기 때문 2.Stress hyperglycemia 3.수술 중 lactate 함유 fluid를 다량 투여 받았을 경우 liver에서 lactate를 glucose로 convert • (혈당이 수술 24-48h 후 증가하는 경향) • Outpatients도 계속하여 N/V 보일 경우 하룻밤동안 입원 필요

  12. The Thyroid Physiology • GI tract 통해 흡수된 dietary iodine은 iodide ion으로 변환되어 thyroid gl.로 active transport • Iodide는 다시 iodine으로 oxidized된 후 tyrosine과 bound하여 triiodothyronine(T3), thyroxine(T4) 형성 • T4 분비량이 더 많지만 T3가 more potent • Thyroid H.역할 • Carbohydrate & fat metabolism 증대 ->Growth & metabolic rate 결정하며 • ( increase in oxygen consumption, CO2 production, indirectly increasing minute ventilation)및 • Heart rate & contractility 증대

  13. HYPERTHYROIDISM Clinical manifestations • Excess thyroid hormone levels • Graves’ disease • Toxic multinodular goiter • Thyroiditis • Thyroid-stimulating-hormone-secreting pituitary tumors • Functioning thyroid adenomas • Overdosage of thyroid replacement hormone • 증상 • Weight loss, heat intolerance, muscle weakness, diarrhea, hyperactive reflexes, nervousness • Graves’ disease : fine tremor, exophthalmos, goiter • Cardiac signs : sinus tachycardia, AF, CHF • 진단 • Total serum T4, serum T3, free (unbound) T4 증가 • Medical treatment • Inhibit hormone synthesis : propylthiouracil, methimazole • Prevent hormone release : potassium, sodium iodide • Mask Sx : propranolol (T4T3 pph. conversion 감소시키기도 함) • Radioactive iodine • Surgical treatment • Subtotal thyroidectomy

  14. Anesthetic considerationsA. preoperative • Medical treatment 통해 euthyroid state 만들어야 함 • 1.thyroid function tests : NL • 2.Resting heart rate < 85 bpm • Antithyroid medications & β-blocker는 수술당일 아침까지 투여 계속 (BENZO.으로 SEDATION 가능) • Emergency surgery • Esmolol infusion 통해 hyperdynamic circulation 조절

  15. B. intraoperative • Cardiovascular function & body temperature monitor • Ketamine, pancuronium, indirect-acting adrenergic agonist 등 교감신경 항진시키는 약제 피할 것 • Thiopental : induction agent of choice • High dose에서 약간의 antithyroid activity 지님 • 대부분 chronically hypovolemic & vasodilated state (Induction시 hypotensive response 위험) • Laryngoscopy or surgical stimulation에 의한 tachycardia, HTN, ventricular arrhythmia 피하기 위해 적절한 마취심도 유지할 것 • NMBAs 주의해서 사용 • (Thyrotoxicosis에서 myopathy, myasthenia gravis 흔함) • Hyperthyroidism은 MAC을 변화시키지 않음

  16. C. postoperative • Thyroid storm • Sx : Hyperpyrexia, tachycardia, altered consciousness (agitation, delirium, coma), hypotension • 대개 술후 6-24h에 발생하지만 술중에도 발생 가능 • Malignant hyperthermia와 감별점 • Muscle rigidity, creatine kinase 증가, 심한 metabolic & respiratory acidosis 없음 • Tx (Medical emergency) • Hydration & cooling • Esmolol infusion • iv propranolol (HR<100/min될때까지 0.5mg씩 증량) • Propylthiouracil (6시간마다 250-500mg씩 경구투여, sodium ioide 먼저 투여) • Cortisol : 동반된 adrenal gland suppression에 따른 합병증 예방 • Hypoparathyroidism • Unintentional removal of parathyroid glands • 12-72시간 내에 acute hypocalcemia 발생 • Unintentional pneumothorax : neck exploration시 위험

  17. HYPOTHYROIDISM Clinical manifestations(1) • 원인 • Autoimmune disease : Hashimoto’s thyroiditis • Thyroidectomy • Radioactive iodine • Antithyroid medications • Iodine deficiency • Failure of hypothalamic-pituitary axis • Clinical manifestations in adult • Weight gain, cold intolerance, muscle fatigue, lethargy, constipation, hypoactive reflexes, dull facial expression, depression • Heart rate, myocardial contractility, stroke volume, cardiac output 감소 • Pph. Extremities are cool & mottled • Pleural, abdominal, pericardial effusions • 진단 • Low free T4 level • Primary hypothyroidism에서는 TSH 증가되어 있음 • 치료 • Oral replacement therapy

  18. Clinical manifestations (2) • Myxedema coma (심한 hypothyroidism에 기인) • 특징 : Impaired mentation, hypoventilation, hypothermia, hyponatremia, CHF • 노인에서 흔하고, infection, surgery, trauma에 의해 유발됨 • 치료 : T3 or T4 loading dose (levothyroxine sodium 300-500mg) 후 maintenance infusion (50mg per day) • 치료 중에 MI나 arrhythmia 발견 위해 반드시 ECG monitoring • Steroid replacement (hydrocortisone 100mg iv per 8h)(Coexisting adrenal gland suppression 때문) • Ventilatory support & external warming 필요할 수도

  19. Anesthetic considerationsA. preoperative • Uncorrected severe hypothyroidism (T4<1mg/dL) or myxedema coma ->Elective surgery 시행 하지 말것 • Emergency surgery에서도 thyroid hormone으로 우선 치료 후 수술 시행 • Premedication • Drug induced respiratory depression에 취약하므로 심한 preop. sedation 금지 • Gastric-emptying time 줄어있으므로 H2 antagonist & metoclopramide 투여 고려 • 수술 당일 아침까지 투여중인 thyroid medication 지속

  20. B. intraoperative • Anesthetic agent에 따른 hypotensive effect에 취약함 (Cardiac output 감소되어 있고, baroreceptor reflex 둔화되어 있으며, intravascular volume 감소되어 있기 때문) • Ketamine • Recommended for induction of anesthesia • Other potential problems • Hypoglycemia • Anemia • Hyponatremia • Difficulty during intubation (large tongue ) • Hypothermia :(low basal metabolic rate )

  21. C. postoperative • 전신마취에서 회복 지연될 수 있음 • 원인 : hypothermia, respiratory depression, slowed drug biotransformation • Prolonged mechanical ventilation 필요할 수도 있음 • Awake & normothermic해질 때까지 intubated 상태로 기다릴 것 • Ketorolac 같은 nonopioid analgesics가 postop. pain 경감에 좋음

  22. THE PARATHYROID GLANDS Physiology(PTH) • Serum calcium 증대시킴 • Bone resorption 촉진, renal excretion 제한, G-I에서의 흡수 증대 • Serum phosphate는 감소시킴

  23. HYPERPARATHYROIDISMClinical manifestations • 원인 • Primary : adenoma, carcinoma, hyperplasia • Secondary : hypocalcemia에 대한 반응으로써 • 증상 • Hypercalcemia에 의한 증상 • 치료 • Surgical removal of all four glands

  24. HYPERPARATHYROIDISM Anesthetic considerations • Volume status 확인 (intu.시 저혈압 방지위해) 1.N/S으로 hydration, furosemide로 diuresis  decrease serum calcium (< 14mg/dL, 7mEq/L, 3.5mmol/L) 2.iv bisphosphonates pamidronate, etidronate • C/I 또는 효과 없을시에는 plicamycin, glucocorticoids, calcitonin, dialysis 필요할 수도 있음 • Hypoventilation 피할 것(산증은 Ca+증가시키므로) • NMBAs: Preexisting muscle weakness 때문에 반응 달라질 수 있음

  25. HYPOPARATHYROIDISMClinical manifestations • 대개 parathyroidectomy 후에 발생 • Hypocalcemia 증상 보임 • Neuromuscular irritability확인 • Chvostek’s sign • Trousseau’s sign • 증상있는 hypocalcemia 치료 위해 iv calcium chloride 투여

  26. HYPOPARATHYROIDISMAnesthetic considerations • Normalization of serum calcium • (Hypocalcemia에 의한 cardiac manifestation 있을 경우) • Myocardium depression시키는 마취약제 피할 것 • Hyperventilation에 의한 alkalosis와sodium bicarbonate 투여 등은 ionized calcium 더 낮추므로 주의 • 5%알부민도 사용금기

  27. THE ADRENAL GLAND Physiology • Two part로 나뉨 • Adrenal cortex • Androgens, mineralocordicoids(aldosterone), glucocorticoids(cortisol) 분비 • Adrenal medulla • Catecholamines(epinephrine, norepinephrine, dopamine) 분비 1.Aldosterone • Fluid & electrolyte balance유지 (Sodium 재흡수시켜 ECF 늘리고 fluid retention, plasma potassium 감소, metabolic alkalosis 유발) • Hypovolemia, CHF, surgery 등은 aldosterone 분비 높임 2.Glucocorticoids • Antiinsulin effect : 혈당 높임 • Vascular & bronchial smooth muscle이 catecholamines에 반응하는데 필요 3.Epinephrine • Hypotension, hypothermia, hypoglycemia, hypercapnia, hypoxemia, pain, fear 등에 의해 분비 촉진됨

  28. MINERALOCORTICOID EXCESS • Unilateral adenoma, bilateral hyperplasisa, carcinoma 등이 원인 • 증상(Na+유입 K+유출 ,ECF증가에 기인) • HTN, hypervolemia, hypokalemia, muscle weakness, metabolic alkalosis • Hypokalemia 길어지면 renal concentrating defect 가져와 polyuria 발생 • Alkalosis는 ionized calcium 감소시켜 tetany 유발 • 수술전 fluid & electrolyte 이상은 교정 필요 • Spironolactone 등 투여 • Intravascular volume은 orthostatic hypotension, cardiac filling pressure 측정으로 판단 가능

  29. MINERALOCORTICOID DEFICIENCY • 증상 • Hyperkalemic, acidotic, hypotensive • Preop. preparation시 mineralocorticoid 투여 (fludrocortisone)

  30. GLUCOCORTICOID EXCESS • Cushing’s syndrome • Muscle wasting & weakness, osteoporosis, central obesity, abdominal striae, glucose intolerance, hypertension, mental status changes • Volume overloaded, hypokalemic metabolic alkalosis되어 있음 • 수술 전 potassium, spironolactone 투여로 교정하여야 함 • 원인이 exogenous glucocorticoid일 경우 수술 자극에 대한 adrenal gland의 반응이 떨어짐 • Steroid 보충이 필요 • IV hydrocortisone succinate, 100mg every 8h

  31. GLUCOCORTICOID DEFICIENCY • Addison’s disease • Aldosterone과 cortisol 함께 부족 • 증상 • Aldosterone 부족 : hyponatremia, hypovolemia, hypotension, hyperkalemia, metabolic acidosis • Cortisol 부족 : weakness, fatigue, hypoglycemia, hypotension, weight loss • Etomiate는 adrenal function을 저해 • Addisonian crisis (acute adrenal insufficiency) • Steroid-dependent Pt가 stress(infection, trauma, surgery) 받는 동안 steroid 투여 늘리지 않았을 때 • Circulatory collapse, fever, hypoglycemia, depressed mentation • 수술전 12개월 동안 2주이상 steroid 투여받았을 경우 surgical stress에 대한 반응 떨어짐 • Adequate steroid replacement therapy 필요 • 수술전날 저녁이나 당일아침부터 8시간마다 hydrocortisone phosphate 100mg씩 투여하거나 • Induction시 hydrocortisone 25mg 투여 후 24시간 동안 100mg infusion

  32. CATECHOLAMINE EXCESS • Pheochromocytoma • Catecholamine-secreting tumor • Paroxysmal headache, hypertension, sweating, palpitation • Unexpected intraop. Hypertension & tachycardia ->1st indications of undiagnosed pheochromocytoma • Preop. Assessment OF Pheochromocytoma • Adequacy of adrenergic blockade & volume replacement • (Arterial BP, orthostatic BP, heart rate, ventricular ectopy, MI의 ECG상의 증거 등) • Direct arterial pressure monitoring, good iv access, urinary output monitoring 필요 • Catecholamine cardiomyopathy 있을 경우 pulm. a. catheter 시행

  33. CATECHOLAMINE EXCESS (2) • Periop. Management • Intubation : deep anesthesia에서 시행 • Intraop. HTN : phentolamine, nitroprusside, nicardipine 등으로 조절 • Nitroprusside : rapid onset, short duration, increased familiarity • Phentolamine : specifically blocks adrenergic receptors • 금기 약제 또는 조작 • Sympathetic nervous system 항진 • Ephedrine, ketamine, hypoventilation • Catecholamine의 arrhythmic effect 강화시키는 약제 : halothane • Parasympathetic nervous system 억제 : pancuronium • Histamine 분비 : atracurium, morphine sulfate • Tumor ligation & resection 후에 hypotension 흔히 발생 • 원인 : hypovolemia, persistent adrenergic blockade, prior tolerance to catecholamine • Fluid resuscitation, assessment of intravascular volume • Infusion of adrenergic agonist : phenylephrine, norepinephrine • Postop. Hypertension • Occult tumor 존재하거나 volume overload 때문

  34. OBESITY • 분류 • Overweight : BMI ≥ 24 ㎏/㎡ • Obesity : BMI ≥ 30 ㎏/㎡ • Extreme obesity : BMI ≥ 40 ㎏/㎡ • Waist measurement (men ≥ 40 in., women ≥ 35 in.) • Increased health risk

  35. Clinical manifestations • Metabolic syndrome : obesity, HTN, type II DM • Oxygen demand, CO2 production, alveolar ventilation 증가 • Abd. mass가 diaphragm을 눌러 lung volume을 줄이고 restrictive lung dis. 나타냄 • (Supine, Trendelenburg position에서 심해짐) • Pulm. HTN & cor pulmonale • Persistent hypoxia로 인한 pulm. Blood flow 증가와 pulm. a. vasoconstriction 때문

  36. Anesthetic considerationsA. preoperative • Premedication • Aspiration pneumonia 위험 • Routine pretreatment with H2 blocker, metoclopramide • Respiratory depressant 피할 것 • Difficult intubation 주의 • Temporomandibular & atlantooccipital joint의 움직임 제한 • Narrowed airway • Shortened distance between mandible and sternal fat pads

  37. Anesthetic considerationsB. intraoperative • 짧은 수술이어도 intubation 시행 • Aspiration 위험 때문 • Large tidal volume으로 controlled ventilation 시행시 oxygenation 더 잘됨 • Lithotomy, Trendelenburg, prone position 시 더 높은 흡기산소농도 필요 • PEEP은 pulm. HTN 악화시킬 수 있음 • Volatile anesthetics의 fat reservoir로의 distribution은 느리므로 긴 수술에서도 wake-up time에의 영향은 미미함 • Lipid-soluble drug의 Vd이 크기 때문에 larger loading dose 필요 • Actual body weight로 dose 결정 • Maintenance dose는 less frequently : clearance 느리므로 • Water-soluble drug은 ideal body weight에 기초로 dose 결정 • Regional anesthesia 어려울 수 있음 • High level blockade시 repiratory compromise 쉬움

  38. Anesthetic considerationsC. postoperative • Respiratory failure 위험 • Extubation은 : full awake된 후에 시행 • RR로 이송 중 산소 공급 지속 • 45o sitting position • 수술 후 수일간 hypoxia 위험 있으므로 산소공급 지속여부 고려 • 기타 Cx • Wound infection, deep venous thrombosis, pulm. embolism 등

  39. CARCINOID SYNDROME Clinical manefestations • Enteroepinephrine tumor로부터 vasoactive substances(serotonin, kallikrein, histamine 등) 분비 • 증상 • Cutaneous flushing, bronchospasm, profuse diarrhea, dramatic swings in arterial BP • Valvular & myocardial plaque 형성에 의한 Rt-sided heart disease와 관련됨 • 치료 • Surgical resection • Symptomatic relief • Specific serotonin & histamine antagonists

  40. Anesthetic considerations • 마취시 tumor로부터의 vasoactive substance 유리 억제 • Hypotension은 hormone release 유발하므로 volume expansion으로 조절 • Catecholamine 투여는 kallikrein activation 유발 • Regional anesthesia는 periop. stress 억제 • Histamine-releasing drug 피할 것 • Morphine, atracurium • Hemodynamic instability • A-line, CVP, pulm. a. catheter 필요