Anaesthesiology and Resuscitation Anaesthesiologie und Wiederbelebung Anesthesiologie et Reanimation 75 Editors Prof. Dr. R. Frey, Mainz' Dr. F. Kern, St. Gallen Prof. Dr. O. Mayrhofer, Wien Managing Editor: Prof. Dr. M. Halmagyi, Mainz
T.Oyama Anesthetic Management of Endocrine Disease With 42 Figures Springer -Verlag Berlin Heidelberg New Y ork 1973
TSUTOMU OYAMA, M. D. Professor and Chairman, Department of Anesthesia, School of Medicine, Hirosaki University, Hirosaki, Aomori-Ken, Japan Visiting Professor, Department of Anesthesiology, University of Miami School of Medicine, Miami, Florida, USA ISBN -13:978-3-540-06181-6 e-isbn -13:978-3-642-65561-6 DOI: 10.1007/978-3-642-65561-6 The use of general descriptive names, trade marks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concemed, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying, machine or similar means, and storage in data banks. Under 53 of the German Copyright Law where copies are made for other than private use, a fee is payable to the publisher, the amount to the fee to be determined by agreement with the publisher. by Springer-Verlag Berlin. Heidelberg 1973. Library of Congress Catalog Card Nurnber 73-75651. Typesetting and printing Universitätsdruckerei Mainz GmbH
Preface Endocrinology is a rapidly developing field with many new concepts. In addition, many new hormones have been described since 1960. The structural analysis and synthesis of several intestinal hormones such as gastrin, secretin, glucagon and cholecystokinin have been achieved. Several hypothalamic hormones controlling pituitary function have been identified and in certain cases synthesized. The existence of hormonal peptides secreted from ectopic sites has been recognized. The development of new techniques of hormone assay has stimulated studies on the effects of anesthetics on the endocrine system. Although the endocrine response to anesthesia is less than its response to major surgical procedures, the effects of anesthesia on metabolism and on the autonomie nervous system are substantial. The primary purpose of this book is to increase the safety of patients undergoing anesthesia by making available the latest developments in this field. The major subjects examined in the book are endocrine responses to anesthesia and surgery, the effects of endocrine disease on anesthesia and surgery, and pre-operative and post-operative management of patients with endocrine disease. The book is designed for students, residents and practicing physicians in the field of anesthesia and surgery. Many tables and figures are empioyed to improve the presentation, particuiarly those relating to pharmacology and to the practical aspects of therapy. I wish to express my deepest appreciation to Dr. C. A. NUGENT, Professor ofinternal Medicine (Endocrinology Section), University of Arizona School of Medicine, and to Dr. F. P. HAUGEN, Emeritus Professor of Anesthesia, University of Oregon School of Medicine. They were kind enough to correct my English, and also gave me heipful advice in editing the book. Furthermore, I would like to thank my colleagues in my Department. Much new information in this field has been developed as a result of their energetic research efforts. I am also grateful to Prof. F. MOYA, University of Miami School of Medicine, for his advice. Finally, the author is grateful to Prof. R. FREY of the Department of Anesthesia, University of Mainz Medical School, and Springer Verlag for the opportunity of having this book published in Germany. Miami, April 1973 T.OYAMA
Table of Contents I. General Principles of Endocrinology II. Hypothalamus.... A. Hypothalamic Functions.... B. The Endocrine Hypothalamic Function 1 2 2 2 III. Pituitary... 5 A. General Discussion................ " 5 B. Physiology of Anterior Pituitary. Effects of Anesthesia and Surgery....................... 5 C. Posterior Pituitary Gland (Neurohypophysis). Effect of Anesthesia and Surgery... 17 D. Hypopituitarism and Anesthetic Management. 24 E. Hypophysectomy and Anesthetic Management 29 IV. Adrenal Cortex 34 A. General Discussion.................. 34 B. Effects of Anesthesia and Surgery on Adrenal Cortieal Function 42 C. Adrenal Hypofunction and Anesthesia......... 52 D. Prediction of Adrenocortical Hypofunction........ 55 E. Applications of Corticosteroids to Anesthesia and Surgery. 57 F. Effects and Significance of Anesthesia and Surgieal Trauma on Postoperative Metabolism............ 59 IV I. Hyperadrenocortical States: Anesthesia for Adrenalectomy A. Cushing's Syndrome B. Aldosteronism lvii. Anesthesia for Addison' s Disease V. Catecholamines A. General Discussion B. Catecholamine Synthesis C. Physiologie Actions of Catecholamines D. Cardiac Responses to Sympathetic Nervous Activity during Anesthesia...................... 60 60 64 71 73 73 75 76 79
vm Table of Contents E. MAO Inhibitors and Anesthesia F. Sympathomimetic Amines G. Beta Blockers and Anesthesia H. Anesthetic Management of Pheochromocytoma 84 86 86 88 VI. Thyroid... 92 A. General Discussion............ 92 B. Effect of Anesthesia and Surgery on Thyroid Function 95 C. Pathophysiology of Thyroid Diseases 97 D. Anesthesia for Hyperthyroidism 101 E. Thyrotoxic Storm (Crisis) 105 VII. Parathyroid...... 107 A. General Discussion 107 B. Hyperparathyroidism 108 VIII. Thymus and Myasthenia Gravis 112 A. General Discussion.... 112 B. Pathophysiology of Myasthenia Gravis 112 C. Anesthesia for Myasthenie Patients 113 IX. Pancreas............. 118 A. Carbohydrate and Fat Metabolism 118 B. Effects of Anesthesia and Surgery on Carbohydrate and Fat Metabolism.............. 122 C. Anesthetic Management of Diabetes Mellitus 126 D. Glucagon............. 135 E. Anesthetic Management of Insulinoma 137 X. Testosterone............. 140 A. General Discussion......... 140 B. Effects of Anesthesia and Surgery on Testosterone 140 XI. Prostaglandins XII. Shock and Endocrinology...... A. The Effect of Injury on Metabolism B. Classification of Shock C. Pathophysiology of Shock D. Shock and Endocrine System E. Treatment of Shock XIII. References. XIV. Subject Index 142 144 144 145 145 146 149 153 215
Introduction In recent years there has been significant expansion in our knowledge and understanding of the field of endorinology. As a result, patients are living longer and coming to surgery for elective incidental procedures or for direct intervention in the endocrine problem. Therefore, the subject matter of this textbook is of great importance and relevance to anesthesiologists, surgeons, and internists alike. The contents of this comprehensive volume includes consideration of all mai,or endocrine functions including the prostaglandins. The interreaction of surgery, anesthesia, endocrine function and their influence on the management of these patients are presented in a scholarly and lucid fashion. Professor OYAMA is eminently qualified to write such a book for he has devoted most of his professional life to this field. Through his personal research efforts he has been a major contributor to the field of endocrine response to surgery and anesthesia. These investigations have given hirn the necessary insight and understanding to be able to write this comprehensive and worthy volume. It represents a fitting capstone to an outstanding career in medicine and research. FRANK MOYA