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disorders
Adrenal Gland
Anatomy was first described in 1563.
Is located above (or attached to) the upper pole
of the kidney.
Is pyramidal in structure and weighs ~ 4 g.
Consists of the adrenal cortex and adrenal
medulla
Activities are regulation of fluid volume and
stress response
The Adrenal
Gland:
Anatomy
Adrenal Histology
The adrenal gland is divided into two parts, adrenal cortex and medulla.
Investigations:
Laboratory Studies
- hypernatremia
- hypokalemia; normokalemia does not exclude
primary hyperaldosteronism. Several studies have
shown that 7-38% of patients with primary
hyperaldosteronism have normal baseline serum
levels of potassium
metabolic alkalosis
-Renin levels are suppressed to less than 1 ng/mL/h
in patients with primary hyperaldosteronism.
-A 24-hour aldosterone excretion rate of greater than
14 ug is diagnostic of primary hyperaldosteronism
Imaging Studies :
- CT scanning
- MRI
Treatment
Medical
Medical therapy is used preoperatively to prevent
the morbidity and mortality associated with
hypertension and hypokalemia, thus decreasing
surgical risk.
Sodium-restricted diet (<80 mEq or <2 g of
sodium per day.
Potassium-sparing agent (first-step agent) such
as spironolactone100 mg initially, increase to 400
mg/d for control of blood pressure.
Potassium supplementation should not be
routinely administered with spironolactone
because of the potential for the development of
hyperkalemia.
Second-step agents include thiazides diuretics,
ACE inhibitors, calcium channel antagonists,
and angiotensin II blockers.
Surgical treatment
Surgery is the main therapy for Conn
syndrome. A laparoscopic adrenalectomy is
favored, when possible
• Anesthetic considerations
Preoperative correction of hypertension, CHF and
volume and electrolytes imbalance specially potassium
is mandatory.
Mineralocorticoid deficiency
( Hypo-aldosteronism )
Atrophy or destruction of both adrenal glands results in a
combined deficiency of Mineralocorticoid and glucocorticoid
( addison disease) .
-Isolated Mineralocorticoid deficiency;
-Unilateral adrenalectomy
-DM -Heparine therapy
-congenital
Clinical Presentasi
Hypotension; due to hypovolemia
Metabolic acidosis
Hyperkalemia; any increase in s. potassium without renal
impairment, hypoaldosteronism should be considered.
Hyponatremia
Anesthetic management
Preoperative preparation includes;
correction of fluid and electrolyte imbalance
exogenous mineralocorticoid, fludrocortison 0.1-0.3
mg\ day.
Glucocorticoid excess
( Cushing syndrome/ disease )
William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
Cushing’s Syndrome vs. Cushing’s
Disease
• Cushing’s syndrome is a syndrome
due to excess cortisol from pituitary,
adrenal or other sources (exogenous
glucocorticoids, ectopic ACTH, etc.)
Skin
Facial plethora
abdominal striae
lanugo facial hair
Hirsutism and Steroid acne
Cushing’s Syndrome
Moon facies •Proximal muscle
Facial plethora weakness
•Easy bruising
Supraclavicular fat
•Hirsutism
pads
•Hypertension
Buffalo hump •Osteopenia
Truncal obesity •Diabetes mellitus/IGT
Weight gain • Impaired immune
function/poor wound
Purple striae healing
Central Obesity in Cushing’s Disease
William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
Progressive Obesity of Cushing’s
Disease
William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
Buffalo Hump in Cushing’s Disease
Orth, D. UpToDate
Striae in Cushing’s Disease
Orth, D. UpToDate
Proximal Muscle Wasting in
Cushing’s Syndrome
William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
Cardiovascular and renal
Hypertension and possibly edema may be present
due to cortisol activation of the mineralocorticoid
receptor leading to sodium and water retention
Gastroenterologic
Peptic ulceration may occur with or without
symptoms.
Endocrine
Galactorrhea and menstrual disturbances
decreased libido and impotence in men.
Skeletal/muscular
Proximal muscle weakness
Osteoporosis and osteopenia
Avascular necrosis of the hip
Neuropsychological
Emotional liability, fatigue, and depression
Visual-field defects, often bitemporal, and blurred
vision
Adrenal crisis
Diagnosis of Cushing’s Syndrome
ACTH, AM cortisol
24 hour urine cortisol
Dexamethasone suppression testing
Midnight salivary cortisol
Dexamethasone Suppression
Test
http://www.endotext.com/neuroendo/neuroendo7/neuroendoframe7.htm
Circadian Studies of Serum Cortisol
Levels
http://www.endotext.com/neuroendo/neuroendo7/neuroendoframe7.htm
Investigations
Laboratory Studies
Hyperglycemia
Hypokalemic metabolic alkalosis
Biochemical evaluation of Cushing syndrome:
1-Urinary free cortisol excretion over 150 ug\ day.
2- dexamethasone suppression test; glucocorticoids
inhibit secretion of hypothalamic CRH and pituitary
ACTH but do not directly affect adrenal cortisol
production. The overnight 1-mg dexamethasone
suppression test requires administration of 1 mg of
dexamethasone at 11 PM with subsequent measurement
of cortisol level at 8 am.4 In healthy individuals, the
serum cortisol level should be less than 2-3 ug/dL.
3-loss of circadian rhythm of cortisol secretion
Normal values, 10-25 ug\ml in the morning, 2-10 ug\ml
in the evening, elevated serum cortisol at 11 PM can
be an early finding.
Recently, measuring salivary cortisol level has gained
interest, as it is a simple and convenient way of
obtaining a nighttime sampl. levels less than 1.3-1.5
ng/mL exclude Cushing syndrome.
4- A plasma ACTH of less than 5 pg/mL is
suggestive of a primary adrenal tumor. An ACTH
level greater than 10-20 pg/mL is consistent with
ACTH-dependent Cushing syndrome.
Imaging studies
CT or MRI brain and abdomen
Diagnosis
24 hr urine cortisol levels
Serum sodium levels
Serum potassium levels
Serum glucose
Serum ACTH in Cushing Disease
ACTH suppression test to identify cause
Dexamethasone supression test: cause pituitary or
adrenal
Radiological exam to reveal pituitary or adrenal tumor
Treatment
Transphenoidal surgery if the condition is due
to a pituitary tumor
Where surgery is contraindicated or fails to
reduce cortisol levels, adrenalectomy and/or
pituitary radiation may be necessary.
Adrenocortical Inhibitors: (metapyrone,
aminogluthimide) are only effective short-term.
Diet: low calorie, carbohydrate & salt. High
potassium.
Treatment
Hypopysectomy for pituitary tumors, or adrenalectomy for
adrenal tumors.
Pituitary irradiation is employed when transsphenoidal
surgery is not successful or not possible
Patients with endogenous Cushing syndrome who
undergo resection of pituitary, adrenal, or ectopic tumors
should receive stress doses of glucocorticoid in the
intraoperative and immediate postoperative period
Lifelong glucocorticoid and mineralocorticoid replacement
is necessary in those patients who undergo bilateral
adrenalectomy.
Anesthetic considerations
Preoperative management
From the C\P those pt. Tend to be volume
overloaded, hypertensive and hypokalemic, so
Preoperative correction of these factors are
essential by potassium and spironolactone.
Intraoperative
Patients with osteoprosis are at risk for fracture
during positioning.
Preoperative weakness may indicate an increased
sensitivity to muscle relaxants.
Supplemental steroids are indicated for patients
with Cushing syndrome due to exogenous
glucocorticoids
patients undergoing adrenalectomy
Dose; I.V. hydrocortisone succinate 100 mg
every 8 h beginning the evening before surgery
or on the morning of surgery.
Other complications of adrenalectomy include
significant blood loss and unintentional
pneumothorax.
Pseudo-Cushing Syndrome
In 1976, Smalls and associates described 3
alcoholic patients who had the physical and
biochemical abnormalities of Cushing syndrome.
Most of the abnormalities disappeared with 1-3
weeks of alcohol abstinence. About 30 cases have
been reported.
Pathophysiology
The mechanism remains unclear. Most evidence
suggests central stimulation of a corticotropin-
releasing hormone, either at the hypothalamic or
suprahypothalamic level.
Persistence of abnormalities may lead to
complications such as hypertension, glucose
intolerance, diabetes mellitus, and osteoporosis.
The most important part of the history is the
extent and duration of alcohol abuse.
Glucocorticoid deficiency
( Addison Disease )
Sex
Idiopathic autoimmune Addison disease tends to be
more common in females and children.