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Core Topics in Endocrinology in Anaesthesia and Critical Care
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Book description

Core Topics in Endocrinology in Anesthesia and Critical Care provides a comprehensive, practical overview of the perioperative management of patients with endocrine disorders, giving clear diagnostic advice and management guidelines. This book considers the management of patients with endocrine disorders of the pituitary, thyroid, parathyroid and adrenal glands, including rarer disorders such as MEN syndrome. It then considers all aspects of the perioperative management of diabetic patients, including paediatric, obstetric and ambulatory patients. Finally it discusses endocrine disorders in the critically ill patient, covering such issues as the topical conundrum of glucose control and the management of diabetic metabolic acidosis, thyroid storm and myxoedema coma. Every chapter reviews the relevant anatomy and pathophysiology and the latest developments in defining the genetic causes are also considered where appropriate. Core Topics in Endocrinology in Anesthesia and Critical Care is an invaluable tool for all anaesthetists and intensivists in their daily clinical practice.

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  • Chapter 8 - Drugs used in diabetes mellitus
    pp 83-92
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    The human neuroendocrine system has two components, hormonal secretion that is controlled by hypothalamo-pituitary axis and extra-hypothalamic neurohormones. Hypothalamus is responsible for the maintenance of homeostasis and the integration of nervous and endocrine control mechanisms. It regulates many of the body's autonomic functions, such as temperature, thirst and hunger, blood pressure and volume, sleep and sexual function, and is intimately related, both anatomically and functionally, to the pituitary gland. The majority of clinically significant pituitary conditions are the result of tumour or tumour-like conditions that arise from either within the gland itself or in surrounding parasellar tissues. The endocrine hyposecretion syndromes associated with pituitary disease of relevance to perioperative care include adrenocortical insufficiency, hypothyroidism and diabetes insipidus. Sellar or parasellar lesions rarely present with failure of posterior lobe function, although it is a relatively frequent complication of surgical resection.
  • Chapter 10 - Management of diabetes in obstetric patients
    pp 101-108
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    Many patients who require anaesthesia have coincidental disease of their thyroid gland. The thyroid gland is situated in the anterior region of the neck just deep to the strap muscles at the level of the C5 to T1 vertebrae. The structural units of the thyroid gland consist of round follicles, or acini, filled with colloid and surrounded by a single layer of epithelial thyroid cells. The signs and symptoms of hypothyroidism are predictable consequences of the physiological effects of the lack of thyroid hormones. Thyrotoxicosis affects approximately 2% of women and 0.2% of men in the general population. The prevalence of hyperthyroidism in iodine-sufficient areas is 2:1000 for overt and 6:1000 for sub-clinical hyperthyroidism. The indications for thyroidectomy include thyroid malignancy, obstructive symptoms, retrosternal goitre, Graves' disease unresponsive to medical treatment, recurrent hyperthyroidism, occasionally Hashimoto's disease and for cosmetic reasons.
  • Chapter 11 - Management of diabetes in paediatric surgery
    pp 109-116
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    This chapter considers the basic anatomy and physiology of the parathyroid gland, followed by its pathologies and their implications for anaesthesia. There are usually two pairs of parathyroid gland, superior and inferior, each measuring 4 x 2 x 6 mm, surrounded by fat and each weighing approximately 25-40 mg. About 80-90% of patients have four parathyroids. Parathyroid hormone is secreted by the parathyroid chief cells in response to the fall in the level of circulating, free calcium. The clinical presentation of primary hyperparathyroidism has altered over the past century. It is a commonly recognised endocrine disorder, with the number of parathyroidectomies increasing each year. The gold standard of treatment and the only hope of cure is surgical parathyroidectomy. Preoperative intravenous infusion of methylene blue is used to identify the parathyroid glands, and in open or minimally invasive surgery the operative times can be reduced.
  • Chapter 12 - Management of diabetes in ambulatory surgery
    pp 117-124
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    The adrenal glands are located at the upper margin of the kidneys about the level of the 12th thoracic vertebra. They are composed of two functional parts, the medulla and the cortex. Disease processes of the adrenal glands that may require surgical intervention result from excessive secretion of one or more of these hormones. A secretory tumour of the medulla is known as a phaeochromocytoma, which produces high circulating concentrations of catecholamines. In the cortex, benign secretory adenomas can produce cortisol resulting in high circulating levels (Cushing's disease) or secrete aldosterone (Conn's syndrome). Prolonged treatment with steroids such as prednisolone can produce secondary adrenocortical insufficiency due to suppression of the normal control mechanisms. This results in profound cardiovascular collapse in the perioperative period. This severe complication can be avoided by supplementation with cortisol.
  • Section 3 - Endocrine disorders in the critically ill
    pp 125-184
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    Pancreatic islet cell tumours and carcinoids are rare, and patients with these tumours form a small part of the case-load of the anaesthetist who regularly undertakes anaesthesia for major abdominal surgery. Insulinoma is the commonest functioning pancreatic neuroendocrine tumour (NET). Gastrinoma is the second commonest functioning pancreatic neuroendocrine tumour, and contrasts with insulinoma in several respects. The absence of symptoms is characteristic of non-functioning tumours. VIPoma is a rare tumour. Secretion of Vasoactive Intestinal Polypeptide produces watery diarrhea. Major upper abdominal surgery involves a bilateral subcostal incision, may last for several hours, requires dissection of lymphatic tissue and causes fluid shifts. It occasionally results in severe blood loss. A. Holdcroft has described a pre-operative checklist for the additional problems of the patient with a NET. Pre-operative investigations include pulmonary function tests, ECG, full blood count, clotting screen, electrolytes and liver function tests.
  • Chapter 14 - Tight glucose control using intensive insulin therapy in the critically ill
    pp 134-143
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    Multiple endocrine neoplasia (MEN) is a rare autosomal dominant disorder characterised by primary tumours in at least two different endocrine glands. In the early twentieth century, a syndrome that involved the concurrence of tumours of the parathyroid glands, the pancreatic islets and the anterior pituitary gland was described. The gene that codes for menin is located on chromosome 11q12-13 and transcribes an mRNA consisting of 10 exons which encodes the 610 amino acid protein, menin. MEN 2 is a rare disorder with a prevalence of one in 20,000, and like MEN 1, is an dominant syndrome. The RET protooncogene, located on chromosome 10q11.2, transcribes an mRNA consisting of 21 exons. Molecular information has revolutionised the understanding and treatment of MEN 2. The increasing knowledge of the molecular mechanisms of MEN coupled with the clinical outcome and the availability of genetic testing has greatly reduced its morbidity and mortality.
  • Chapter 15 - Glucocorticoids in the critically ill
    pp 144-154
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    The International Diabetes Federation estimated that in 2008 there were 246 million adults worldwide with diabetes mellitus (DM), and the prevalence is expected to reach at least 380 million by 2025. Diabetes is diagnosed on the basis of criteria agreed by the World Health Organization (WHO) in 1999. Destruction of the pancreatic ß-cells is characteristic of type 1 DM and usually results in an absolute deficiency of insulin. The principles of management of type 1 DM are based on the detailed observations made in two major trials; the Diabetes Control and Complications Trial (DCCT) and the subsequent Epidemiology of Diabetes Interventions and Complications study (EDIC). Hypoglycaemia is a major concern for many type 1 diabetic patients and is usually described as mild, moderate or severe. Most of the increased morbidity and mortality associated with DM is the result of the micro- and macrovascular complications.
  • Chapter 17 - Thyroid dysfunction and critical care
    pp 168-174
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    Diabetes mellitus (DM) is characterised by an absolute or relative deficiency of insulin. There are currently eight different pharmacological classes of anti-diabetic agents. These include agents that increase insulin secretion, improve insulin action and delay carbohydrate absorption. The classes of anti-diabetic agents are sulphonylureas, meglitinides, biguanides, thiazolidinediones, α-glucosidase inhibitors, GLP-1 (glucagon-like peptide-1) receptor agonists, DPP-4 (dipeptidyl peptidase-4) inhibitors and synthetic amylin analogues. Sulphonylureas are known as insulin secretagogues as their major mechanism of action is to increase insulin secretion. The glinides are newer insulin secretagogues that include the meglitinide, repaglinide, and a benzoic acid derivative, and the amino acid derivative, nateglinide. Metformin and phenformin were introduced for the therapy of DM in the 1950s. Thiazolidinediones (TZDs), like metformin, belong to the class of drugs known as insulin sensitisers. Incretins are gut-derived peptides secreted in response to meals, specifically the presence and absorption of nutrients in the intestinal lumen.
  • Chapter 18 - Disorders of sodium balance
    pp 175-184
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    Surgery may be undertaken for the complications of diabetes mellitus (DM), such as coronary artery disease, peripheral vascular disease and renal failure, or the diabetes may be unrelated to the surgical procedure. The aims of metabolic management perioperatively are to avoid hypoglycaemia, excessive hyperglycaemia, and minimise lipolysis and proteolysis by the provision of exogenous glucose and insulin. In the virtual absence of clinical studies in general surgery, and considering the basic biological data on the harmful effects of hyperglycaemia, it is reasonable to recommend that blood glucose should be maintained in the range of 6-10 mmol l-1. There is general agreement that all type 1 diabetic patients should be managed with an intravenous glucose-insulin-potassium (GIK) infusion for inpatient surgery. It is common practice to administer the glucose infusion in the GIK regimen at 100-125 ml h-1.


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