Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942008000200010
Brazilian Journal of Anesthesiology
Clinical Information

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

Anesthesia in a patient with multiple endocrine abnormalities: case report

Renato Toledo Maciel; Fátima Carneiro Fernandes; Leonel dos Santos Pereira

http://dx.doi.org/10.1590/S0034-70942008000200010 Braz J Anesthesiol, vol.58, n2, p.172-178, 2008
PDF Português
PDF English
Downloads: 0
Views: 1012

Resumo

JUSTIFICATIVA E OBJETIVOS: O insulinoma é o tumor endócrino pancreático mais comum. Pode estar associado a neoplasias endócrinas múltiplas (NEM). Relatou-se o caso de paciente com distúrbios endócrinos múltiplos que, no entanto, não se enquadram em síndromes (NEM) já conhecidas e com particularidades clínico-anestésicas que influenciaram no manuseio de sua anestesia. RELATO DO CASO: Paciente feminina, 23 anos, apresentando hipoglicemias de difícil controle associadas à doença de Cushing e prolactinoma, sem sintomas compressivos hipofisários e com estudos de tireóide e de paratireóides sem alterações. A investigação laboratorial encontrou massa retroperitoneal de etiologia desconhecida que, relacionada à situação clínica, levou a hipótese de insulinoma. Relatava ainda ser testemunha de Jeová. A proposta terapêutica era biópsia da massa por videolaparoscopia e enucleação do insulinoma. Ao exame: obesa, dentes protrusos, Mallampati 3 e sintomas de apnéia obstrutiva do sono. Nos exames laboratoriais, o resultado relevante foi o hematócrito de 58%. Recebeu midazolam (7,5 mg) e clonidina (200 µg) via oral como medicação pré-anestésica. A indução anestésica foi realizada com fentanil (150 µg), clonidina (90 µg), propofol (150 mg) e pancurônio (8 mg), sendo realizada a intubação traqueal sem problemas. Foram estabelecidos acesso venoso central e monitoração invasiva da pressão. Mantida infusão de glicose 5% com eletrólitos e monitorada a glicemia capilar a cada 30 minutos, que não acusou episódios de hipoglicemia durante a intervenção cirúrgica. Manteve-se hemodinamicamente estável mesmo durante o pneumoperitônio. No pós-operatório apresentou episódios de hipoglicemia que motivaram sua reoperação. CONCLUSÕES: A singularidade do caso está na conjunção de múltiplas endocrinopatias e de particularidades do manuseio cirúrgico-anestésico. A exérese do insulinoma deve ser monitorada no intra-operatório para que se evitem ressecções incompletas do tumor. A multiplicidade dos desafios em um só paciente exige do anestesiologista o conhecimento de cada obstáculo e suas interações, traçando estratégias para contorná-los.

Palavras-chave

DOENÇAS, Endócrina: insulinoma, hipoglicemia, síndrome endócrina múltipla, doença de Cushing, prolactinoma, policitemia

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 surgical-anesthetic 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.

Keywords

DISORDERS, Endocrine: insulinoma, hypoglycemia, multiple endocrine syndrome, Cushing's disease, prolactinoma, polycythemia

References

Breivik H. Perianaesthetic management of patients with endocrine disease. Acta Anaesthesiol Scand. 1996;40:1004-1015.

Graham G, Unger B, Coursin D. Perioperative management of selective endocrine disorders. Int Anesthesiol Clin. 2000;38:31-67.

Grant F. Anesthetic considerations in the multiple endocrine neoplasia syndromes. Curr Opin Anaesthesiol. 2005;18:345-352.

Suffecool SL. Anesthetic management for insulinoma resection. Contemp Anesth Pract. 1980;3:11-17.

Arens JF. Issues in the anesthetic management of cancer patients. ASA Refresher Courses Anesthesiol. 2004;32:1-7.

Roizen MF, Fleisher LA. Anesthetic Implications of Concurrent Diseases. Miller's Anesthesia. 2005:1017-1049.

Nakagawa M, Sasakuma F, Kishi Y. A successful monitoring for intraoperative calcium stimulation test in complete resection of pancreatic insulinoma. Anesth Analg. 2001;93:239-240.

Pulver JJ, Cullen BF, Miller DR. Use of the artificial beta cell during anesthesia for surgical removal of an insulinoma. Anesth Analg. 1980;59:950-952.

Muir JJ, Endres SM, Offord K. Glucose management in patients undergoing operation for insulinoma removal. Anesthesiology. 1983;59:371-375.

van Heerden JA, Edis AJ, Service FJ. The surgical aspects of insulinomas. Ann Surg. 1979;89:677-682.

Diltser M, Camu F. Glucose homeostasis and insulin secretion during isoflurane anesthesia in humans. Anesthesiology. 1988;68:880-886.

Thompson GB, Service FJ, van Heerden JA. Reoperative insulinomas, 1927-1992: an institutional experience. Surgery. 1992;114:1196-1206.

Tutt GO, Edis AJ, Service FJ. Plasma glucose monitoring during operation for insulinoma: a critical reappraisal. Surgery. 1980;88:351-356.

Correnti S, Liverani A, Antonini G. Intraoperative ultrasonography for pancreatic insulinoma. Hepatogastroenterology. 1996;43:207-211.

Aoki T, Sakon M, Ohzato H. Evaluation of preoperative and intraoperative arterial stimulation and venous sampling for diagnosis and surgical resection of insulinoma. Surgery. 1999;126:968-973.

Nemergut EC, Dumont AS, Barry UT. Perioperative management of patients undergoing transsphenoidal pituitary surgery. Anesth Analg. 2005;101:1170-1181.

Sugihara N, Shimizu M, Shimizu K. Disproportionate hypertrophy of the interventricular septum and its regression in Cushing s syndrome: report of three cases. Intern Med. 1992;31:407-413.

Smith M, Hirsch NP. Pituitary disease and anaesthesia. Br J Anaesth. 2000;85:3-14.

Krinsley J. Perioperative glucose control. Curr Opin Anesthesiol. 2006;19:111-116.

Ljungqvist O, Nygren J, Soop M. Metabolic perioperative management: novel concepts. Curr Opin Crit Care. 2005;11:296-299.

Machado C, Yamashita AM, Togeiro SMGP. Anestesia e apnéia obstrutiva do sono. Rev Bras Anestesiol. 2006;56:669-678.

Loadsman JA, Hillman DR. Anaesthesia and sleep apnoea. Br J Anaesth. 2001;86:254-266.

Shipley JE, Schteingart DE, Tandon R. Sleep architecture and sleep apnea in patients with Cushing s disease. Sleep. 1992;15:514-518.

Benumof JL. Obesity, sleep apnea, the airway, and anesthesia. ASA Refresher Courses Anesthesiol. 2002;30:27-40.

Klibanski A, Neer RM, Beitins IZ. Decreased bone density in hyperprolactinemic women. N Engl J Med. 1980;303:1511-1514.

Joris JL. Anesthesia for Laparoscopic Surgery. Miller's Anesthesia. 2005:2285-2306.

Jorgensen JO, Lalak NJ, North L. Venous stasis during laparoscopic cholecystectomy. Surg Laparosc Endosc. 1994;4:128-133.

Kumar A, Anel R, Bunnell E. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004;32:691-699.

Michard F, Boussat S, Chemla D. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134-138.

5dd6cca00e8825f05513f286 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections