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Anesthesia for Endocrine Disease
TEXTCoexisting Disease · 9 min read
Diabetes, thyroid, adrenal, pituitary, pheo. Each one rewrites your induction plan and your postop disposition.
After this lesson you can
2 min read6 sections- Manage diabetes peri-op.
- Apply stress-dose steroid protocols.
- Recognize thyroid disorders peri-op.
- Plan for pheochromocytoma.
Diabetes mellitus
Periop glycemic target 140-180 mg/dL per current ASA/SAMBA + 2026 ADA Standards consensus (avoid <140 to limit hypoglycemia risk; some institutional protocols still target 110-180).
Long-acting insulin (glargine/detemir): give 80% of usual dose night before/morning of.
NPH: half-dose morning of.
Short-acting + oral hypoglycemics: hold morning of.
SGLT2 inhibitors: hold 3-4 days pre-op (euglycemic DKA risk).
Metformin: hold day of (lactic acidosis with contrast/AKI).
Insulin pump: continue basal at reduced rate during short cases; switch to IV insulin for long/major cases.
Check BG q1 hr intra-op.
Autonomic neuropathy labile BP, gastroparesis (RSI), silent ischemia.
Stiff-joint syndrome difficult intubation (atlanto-occipital limitation, 'prayer sign').
Thyroid disease
Pre-op: methimazole/PTU + beta-blocker + iodide.
- tachycardia
- hyperthermia
- hypotension
- altered mental status — treat with cooling
- IV beta-blocker (esmolol)
- PTU
200-400 mg - hydrocortisone
100 mg - KI 1 hr after PTU (Wolff-Chaikoff)
Hypothyroid — mild OK for surgery; severe (myxedema) postpone for replacement.
Hypothyroid patients sensitive to anesthetics, hypothermia-prone, decreased MV response to CO₂.
Avoid ketamine (no real benefit; tachycardia in hyperthyroid).
Goiter — preop airway eval (CT for tracheal deviation/compression), awake fiberoptic if severe.
Adrenal disease
100 mg IV at induction, then 100 mg q8h for major surgery50 mg q8h for moderateSecondary insufficiency from chronic exogenous steroid (≥5 mg/day prednisone or equiv for ≥3 weeks in past year) — stress-dose.
Cushing syndrome — hypertension, hyperglycemia, OSA, thin skin, osteoporosis (fragile positioning), psychiatric.
Conn syndrome (primary aldosteronism) — hypokalemia, HTN; correct K + spironolactone preop.
Pheochromocytoma
- orthostatic hypotension
- nasal congestion
- no paroxysms
- nitroprusside
- phentolamine
- magnesium
- nicardipine
Tumor manipulation catecholamine surge.
Tumor ligation sudden hypotension (catecholamine washout + alpha-blockade) — anticipate, have vasopressors ready.
- succinylcholine (fasciculation → catecholamine release)
- histamine-releasers (morphine, atracurium)
- ketamine
- ephedrine
- droperidol
- metoclopramide
Pituitary surgery
- airway shared with surgeon
- throat pack
- smooth emergence essential (avoid coughing/straining → CSF leak)
Cushing tumors all Cushing precautions + stress-dose steroid post-resection.
Acromegaly difficult airway (macroglossia, prognathism, OSA, soft tissue), diabetes, HTN.
Diabetes insipidus post-op — track UOP, Na trend; treat with DDAVP if dilute polyuria + rising Na.
SIADH possible post-op — opposite (oliguria + hyponatremia + concentrated urine).
Carcinoid syndrome
- flushing
- bronchospasm
- hypotension or HTN
Pre-op octreotide 100-500 mcg SC q8h × days, plus bolus before induction.
Intraop hypotension — octreotide bolus (NOT epinephrine — paradoxically worsens by triggering more mediator release).
Avoid histamine-releasers + sympathetic activators.
Have octreotide drawn up.
⚠ Common pitfalls
- Tight intraop glucose control — hypoglycemia harms more than mild hyperglycemia.
- Universal stress-dose steroids — risk-stratified by daily dose + duration.
- Beta-blocker before alpha in pheochromocytoma — unopposed alpha → hypertensive crisis.
- Continuing insulin pump without protocol — variable basal rates need coordination.
💎 Clinical pearls
- Diabetes: hold morning oral hypoglycemics + half basal insulin; target glucose 140-180.
- Pheo prep: alpha block ×2 weeks → then beta if tachycardia (NEVER reverse order).
- Thyroid storm: cooling + beta-block + thionamide + iodine + steroid.
- Stress-dose hydrocortisone: low risk = none, moderate = 50 mg + 25 mg q8h, high = 100 + 50 q8h.
Recap
- Diabetes: hold morning oral hypoglycemics + half basal insulin; target glucose 140-180.
- Pheo prep: alpha block ×2 weeks → then beta if tachycardia (NEVER reverse order).
- Thyroid storm: cooling + beta-block + thionamide + iodine + steroid.
- Stress-dose hydrocortisone: low risk = none, moderate = 50 mg + 25 mg q8h, high = 100 + 50 q8h.
Mark each section done to complete the module.