Anestesia para paciente portadora de múltiplas afecções endócrinas: relato de caso

Abstract

BACKGROUND AND OBJECTIVES:Insulinoma is the most common pancreatic endocrine tumor and it can be associated with multiple endocrine neoplasia (MEN). This is a report on a patient with multiple endocrine abnormalities, who did not fulfill the criteria of known syndromes (MEN) and the clinical-anesthetic particularities that influenced the anesthetic management. CASE REPORT:A 23-year old female patient with episodes of hypoglycemia difficult to control, associated with Cushing's disease and prolactinoma without symptoms of pituitary compression and with normal thyroid and parathyroid. Investigation found a retroperitoneal mass of unknown origin which in face of the clinical presentation raised the hypothesis of insulinoma. The patient also referred to be a Jehovah's Witness. Biopsy of the mass by videolaparoscopy and enucleation of the insulinoma were proposed. On physical exam the patient was overweight, had protruding teeth, she was classified as Mallampati 3 and had symptoms of sleep apnea. Laboratorial exams revealed hematocrit 58%. Pre-anesthetic medication consisted of oral midazolam (7.5 mg) and clonidine (200 µg). Fentanyl (150 µg), clonidine (90 µg), propofol (150 mg) and pancuronium (8 mg) were used for anesthetic induction and she was intubated without intercurrences. Central venous access and invasive blood monitoring were instituted. Intravenous infusion of D5W with electrolytes was instituted and capillary glucose levels were monitored every 30 minutes, which did not demonstrate any episodes of hypoglycemia during the surgery. The patient remained hemodynamically stable even during the pneumoperitoneum. She developed postoperative episodes of hypoglycemia, which motivated the re-operation. CONCLUSIONS:This case is unique due to the presence of multiple endocrine abnormalities and the particularities of the surgicalanesthetic management. Intraoperative monitoring is mandatory during removal of an insulinoma to avoid incomplete tumor resection. Multiple challenges in one patient demand the knowledge, by the anesthesiologist, of each obstacle and its interactions in order to devise strategies to control them.

Anesthetic experiences of myxoma removal surgery in two patients with Carney complex -A report of two cases-

“…Cushing's syndrome due to primary pigmented adrenocortical disease appears to be adrenocorticotropic hormone-independent and its diagnosis is difficult because hypercortisolism progresses over several years [1,2]. Therefore, in diagnosing Carney complex, evaluation of the adrenal function and Cushing's syndrome related features such as fluidelectrolyte imbalance hypertension, diastolic dysfunction, glucose intolerance, and thromboembolic risk is essential [2,6]. …”

“…Clinical features are multiple endocrine tumor, skin tumor, pigmented skin lesions, myxomas, and schwannomas [1,2]. Carney complex can cause multiple endocrine dysfunctions in the pituitary gland, thyroid gland, adrenal gland, and testicular gland and induce difficult airway from acromegaly [3,4] and hemodynamic instability from adrenal gland dysfunction [1,5,6]. …”

Insulinoma and anaesthetic implications

“…The anaesthetic technique should include drugs that decrease the cerebral metabolic rate for oxygen (CMRO 2 ). [3839] Both thiopentone sodium and propofol reduce CMRO 2 . Propofol has an advantage over thiopentone sodium as the latter can cause severe hypotension in patients receiving diazoxide therapy because both are protein-bound drugs.…”

“…[37] Moreover, propofol has no effect on the release of insulin and glucose regulation. [3839] For these reasons, some study groups recommended the use of propofol. [4041] Investigators also commented that combination of general anaesthesia with propofol and epidural block is a useful choice of anaesthesia for removal of insulinoma.…”