Endocrinology
Clinical aspects of
endocrinology
Mark Heining
Abstract
Providing anaesthesia for surgery of the endocrine system requires
an understanding of the physiology, pathology, anatomy and pharmaco­
logy of the endocrine organs. The physiology and pharmacology deter­
mine how the patient’s condition may be controlled preoperatively and
what disturbances may happen intraoperatively and postoperatively. The
anatomy and surgical pathology determine the nature and extent of the
procedure and (in the case of the thyroid gland) any likely impact on air­
way control. This article discusses anaesthetic management for surgery
of the thyroid and parathyroid glands and for surgery related to condi­
tions of the adrenal cortex. In the case of thyroid surgery, the impor­
tance of tracheal distortion, control of thyrotoxicosis and occurrence of
post­operative airway problems are emphasized. For parathyroid surgery,
the consequences of hypercalcaemia and of a sudden reduction in para­
thyroid hormone concentrations are discussed. Conditions of the adrenal
cortex vary in severity and often require judgement as to preoperative
optimization, the use of invasive monitoring and the appropriateness
of postoperative critical care. These issues are discussed. Postoperative
pain is rarely a problem (particularly with the increased use of laparo­
scopic surgery) and postoperative stay is short. Some ­ procedures are
now being performed as day cases with careful postoperative protocols.
The input of a motivated endocrinologist is essential both for preopera­
tive management of these sometimes complex cases and for postopera­
tive management of hormone replacement. Close collaboration among
surgeon, anaesthetist and endocrinologist is essential.
Keywords adrenal cortex; Conn’s syndrome; Cushing’s ­syndrome; endo­
crine; hypercalcaemia; parathyroid; thyroid; thyrotoxicosis
Surgical management of endocrine disorders frequently presents
challenges to the anaesthetist. Even the straightforward case
requires an understanding of endocrine anatomy, physiology and
pathology to determine how this affects surgical and anaesthetic
management.
This article will consider surgery of the thyroid and parathy-
roid glands, plus Cushing’s and Conn’s syndromes. Other endo-
crine disorders, particularly phaeochromocytoma and pituitary
disorders, are covered elsewhere in this series.
Mark Heining, MD, FRCA, is Consultant Anaesthetist at Nottingham
University Hospitals NHS Trust, Nottingham.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7
Thyroid surgery
Indications for thyroidectomy are listed in Table 1. Subtotal thy-
roidectomy is rarely performed nowadays, so the operation of
choice for thyrotoxicosis is total thyroidectomy.
Priorities in preoperative assessment are ensuring that thyroid
function is normal and ascertaining the course of the trachea if
there is a significant goitre. Clinical assessment of thyroid function
is an interesting clinical exercise but unreliable – ­measurement
of thyroxine and tri-iodothyronine is essential. Table 2 gives the
details of current anti-thyroid drugs. Effective medical manage-
ment of thyrotoxicosis is essential; however, this may be more
difficult than it might appear because patients may develop phar-
macological side effects and a few appear resistant to standard
anti-thyroid drugs. Management of these patients requires clini-
cal judgement as to the timing of surgery in relation to the degree
of disease control, consideration of the use of beta-­blockade pre-
operatively and close liaison with an interested endocrinologist.
If surgery is being carried out for thyrotoxicosis, an ECG is neces-
sary to exclude the presence of atrial fibrillation.
Patients with a significant goitre require imaging to visual-
ize the course and calibre of the trachea. Symptoms are a poor
indicator of glottic or subglottic narrowing, so imaging should
be carried out on all but the smallest goitres. This is done not
to predict difficult intubation, because any anatomical problem
will be subglottic, but to be a predictor both of tracheal tube size
(if the trachea is narrowed) and of the consequences of surgical
retraction on the trachea (if the trachea is greatly displaced). This
applies even if the goitre is labelled as ‘retrosternal’ or ‘subster-
nal’. A range of imaging techniques is available for the thyroid,
but a plain thoracic inlet view is normally the most informative.
Preoperative assessment of vocal cord function by an ENT
surgeon may be carried out, depending on local arrangements.
In some centres, this will be done for all patients presenting for
thyroid surgery, whereas in others it is done more selectively, for
example if there are symptoms of stridor or hoarseness or if there
has been previous thyroid surgery.
Anaesthesia for thyroid surgery is carried out with a general
anaesthestic using muscle relaxation and intubation with a re­­
inforced tracheal tube. Use of a laryngeal mask airway with
spontaneous ventilation and local–regional anaesthesia have
both been described but have not achieved any popularity in the
Indications for thyroidectomy
• Thyrotoxicosis: recurrent, or with intolerance of anti-thyroid
drugs
• Suspicion, or definite diagnosis, of thyroid cancer: normally
following fine-needle aspiration cytology (FNAC) in the
surgical clinic. Depending on the type of cancer, the operation
may be hemithyroidectomy or total thyroidectomy, and either
may be accompanied by local lymph node clearance
• Benign goitre with associated symptoms: stridor,
breathlessness or dysphagia. Depending on the extent of
the goitre, the operation may be hemithyroidectomy or total
thyroidectomy
Table 1
295 © 2008 Elsevier Ltd. All rights reserved.
 Endocrinology
Anti-thyroid drugs and their associated problems
• Carbimazole The standard anti-thyroid drug in UK practice.
Inhibits the process of iodination in the thyroid gland. Most
important side effect is neutropenia
• Propylthiouracil An alternative to carbimazole, it also reduces
the conversion of thyroxine to tri-iodothyronine in peripheral
tissues
• Propranolol May be added to specific anti-thyroid treatment
if there are obvious cardiovascular signs or if control is
borderline. Besides improving the cardiovascular features,
it also improves control by reducing the conversion of
thyroxine to tri-iodothyronine in peripheral tissues. More
selective beta-blockers lack this latter effect
• Lugol’s iodine Has traditionally been given for a few days
preoperatively to reduce the vascularity of a toxic gland. It is
used less often nowadays because the degree of vascularity
is less important in total thyroidectomy than in subtotal
thyroidectomy
Table 2
UK. An inhalational induction may be used if there is significant
stridor. As already mentioned, the presence of a goitre does not
itself make intubation difficult because the tube normally fol-
lows the contours of the trachea once it is through the vocal
cords. The tube must be secured carefully (avoiding ties around
the neck) and particular attention given to eye protection, espe-
cially in the presence of obvious exophthalmos. The patient is
normally positioned with significant neck extension, so care is
needed in patients with cervical spine problems.
Problems which may arise during surgery include thyroid
crisis and tube displacement. Thyroid crisis may occur during
any surgery in a patient with uncontrolled thyrotoxicosis and
results from excessive release of thyroid hormones. The clinical
picture is one of a hypermetabolic state, including tachycardia,
hypertension and a rise in temperature. This should not occur if
thyroid function has been adequately controlled preoperatively,
but if necessary it should be treated symptomatically with beta-
blockade and other supportive treatment. Unfortunately, there
is no easily available parenteral preparation of any anti-thyroid
drug, so specific treatment requires access to the oral or naso-
gastric route.
Tube displacement tends to occur during retraction of a dis-
placed trachea, with the tube being displaced upwards through
the vocal cords. A useful warning sign is the development of
a leak around the tube cuff as it sits between the vocal cords,
and management is obviously re-intubation (with its attendant
disruption of the surgical procedure). Retraction on the trachea
may also cause occlusion of the tube, demonstrated by high air-
way pressures or complete obstruction. Communication with the
surgeon is important, and ventilation may need to be suspended
for a brief period (up to 30 seconds or so) during a particular part
of the dissection.
The vast majority of goitres which spread substernally can
be extracted through the standard neck incision because the
blood supply to the gland is entirely from above, so sternotomy
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7
is rarely required. The obvious exception is the patient who has
had previous mediastinal surgery, in whom adhesions to the
gland in the mediastinum may have developed. Sternotomy is
then indicated.
Significant blood loss during thyroid surgery is rare, but loss
of 1–1.5 litres may occur with persistent ooze during protracted
surgery. Air embolism during thyroid surgery has been described,
but is very rare. A head-up tilt of about 5° is frequently used
and reduces venous ooze without obviously contributing to air
embolism.
At the end of surgery, residual neuromuscular blockade is
reversed and the patient extubated once adequate spontaneous
ventilation has returned. It is usual to extubate the patient at
a deep plane of anaesthesia to prevent coughing and straining,
which may aggravate or trigger surgical bleeding. Traditionally,
the vocal cords have been inspected laryngoscopically at the end
of surgery to check for recurrent laryngeal nerve damage. The
tendency nowadays is to regard this as technically difficult and
clinically uninformative, so it is rarely required.
With modern specialist surgery, the recurrent laryngeal nerve
is normally identified and dissected out meticulously, so any
postoperative voice change is temporary and caused by intra­
operative pressure or retraction on the nerve. If bilateral recur-
rent laryngeal nerve palsy is present (perhaps because one has
been damaged previously and the other rendered ischaemic dur-
ing the current operation), then there is respiratory obstruction
on extubation. This occurs because the cord adductor muscles
are then the dominant force. Re-intubation through the closed
glottis is required.
Tracheomalacia (weakening of the tracheal wall as a result of
long-standing goitre) is mentioned in most textbooks but is rarely
seen in UK practice (no cases in more than 2000 thyroidectomies
in the author’s unit). A malignant thyroid tumour may, of course,
infiltrate the trachea and so weaken the tracheal wall.
The other major postoperative complication is bleeding. Bleed-
ing from the surgical field may cause respiratory obstruction by
haematoma formation preventing venous return from the upper
neck, causing laryngeal oedema. Clearly, significant bleeding
(normally into a surgical drain) requires prompt return to theatre
for haemostasis. If the airway is under imminent threat, return
to theatre should be even prompter, as re-intubation with expert
assistance and controlled conditions is required. Releasing skin
clips or removing sutures on the ward is unlikely to be helpful.
It will not release a haematoma from a deeper tissue plane, risks
worsening the situation by aggravating surgical bleeding and is,
at best, an unnecessary distraction.
Postoperative pain is rarely a major problem, especially if the
surgeon has infiltrated the surgical site with local anaesthetic.
Paracetamol and non-steroidal anti-inflammatory drugs may
be prescribed, with intermittent morphine (oral or parenteral)
as required. Standard patient-controlled analgesia is suitable if
­sternotomy has been required.
Postoperative nausea and vomiting are relatively frequent
since most of the patients are female and surgery is in a poten-
tially sensitive site. Vomiting, like coughing, is not only unpleas-
ant but may also provoke surgical bleeding, so prompt, effective
treatment or prophylaxis is desirable.
Occasionally, hypocalcaemia follows thyroid surgery, if one
or more parathyroid glands have been damaged or rendered
296 © 2008 Elsevier Ltd. All rights reserved.
 Endocrinology
temporarily ischaemic. Diagnosis and management of this are
described below.
Parathyroid surgery
Parathyroidectomy is performed for hyperparathyroidism, in
order to correct the resulting hypercalcaemia. Hypercalcaemia
arises from excessive renal reabsorption and from excessive
osteoclast activity and bone resorption. Hyperparathyroidism
may be primary, that is, not following another condition, or sec-
ondary, most commonly in association with chronic renal failure.
The first is usually attributable to a solitary adenoma, so requires
removal of a single gland, whereas the second is usually caused
by diffuse hyperplasia of the glands and requires removal of three
or four glands. Tertiary hyperparathyroidism is also described,
in which one of the hyperplastic glands in secondary disease
becomes autonomous and undergoes adenomatous change. In
primary disease, an attempt is made to identify the affected gland
preoperatively, either by ultrasound or by isotope scanning, or
both. This allows confident identification of the affected gland
at surgery, so reducing operative time. Other imaging is not ne­­
cessary as the parathyroid gland does not distort the airway. In
secondary disease, preoperative scanning is rarely necessary as
the aim is to remove all four glands, and these are usually easily
identified at the time of surgery.
Specific preoperative issues are listed in Table 3. Occasionally,
there is severe hypercalcaemia which presents with confusion,
electrolyte imbalance and dehydration. In these cases, surgery
may be relatively urgent as the patient needs to remain in hos-
pital with intravenous fluids, frequent monitoring of electrolyte
levels, etc. Otherwise, the finding of elevated serum calcium lev-
els should not cause anxiety for the anaesthetist. There is rarely a
clinical problem until the serum calcium concentration approaches
4 mmol/litre and medical treatment of hypercalcaemia before sur-
gery is necessary only if symptoms are present. Treatment then
comprises intravenous rehydration (up to 5–6 litres of isotonic
saline in 24 hours), diuretics and sometimes pamidronate. The
Clinical features of hyperparathyroidism of relevance
to the anaesthetist
• Hypertension There is an increased incidence of this condition
• Dehydration, often associated with polyuria and
polydipsia  The raised plasma calcium concentration impairs
renal concentrating ability, so inappropriately dilute urine is
produced
• Anaemia High concentrations of parathyroid hormone reduce
the bone marrow response to erythropoietin (whether
intrinsic or given as a pharmacological agent). This can be
a particular problem in patients with chronic renal failure
presenting with secondary hyperparathyroidism
• Depression, mood swings, sometimes progressing to overt
psychosis
• Possible ECG changes (short Q–T interval), but overt
cardiovascular compromise (arrhythmias, cardiovascular
collapse) is rare
Table 3
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7
advice of a specialist in calcium disorders is recommended, par-
ticularly in relation to which patients are likely to respond to
pamidronate. This is because pamidronate is of value only if there
is documented excessive bone reabsorption.
Perioperative management is straightforward, bearing in
mind that these patients are frequently elderly, hypertensive
and slightly dehydrated. As with thyroid surgery, use of muscle
relaxation and intubation with a reinforced tube is usual. Dura-
tion of surgery varies from about 45 minutes in a straightforward
case with preoperative localization to 3–4 hours in a case with
a difficult repeat procedure with several frozen-section samples
required.
Postoperative pain is even less of a problem than it is with
thyroid surgery and the approach is the same.
Clinically significant hypocalcaemia may follow parathy-
roidectomy and is diagnosed by the presence of Chvostek’s and
Trousseau’s signs. Hypocalcaemia is more likely if there is sig-
nificant bone disease because bone takes up calcium voraciously
once the excess parathyroid stimulus is removed. Treatment is
with slow intravenous calcium.
Parathyroidectomy under local anaesthetic has also been
described and has achieved more popularity than thyroid surgery
under local anaesthetic. It may be carried out with local infiltra-
tion or cervical plexus blockade. This is done as a day case, in
those with clear preoperative localization, with the patients being
given calcium supplements to take at home to prevent hypocal-
caemia. Of course, it should also be possible to undertake this
short surgery (less than 1 hour) under general anaesthesia as a
day case, with appropriate discharge arrangements.
Adrenalectomy for adrenocortical pathology
Adrenalectomy may be carried out for Conn’s syndrome or Cush-
ing’s syndrome. These causes of secondary hypertension occur
because of oversecretion of mineralocorticoid and glucocorticoid
respectively. Surgery is virtually always carried out laparoscopi-
cally as the tumours themselves are small and easily extracted
through a small incision.
Conn’s syndrome classically presents with hypertension and
hypokalaemia. Occasionally, there is glucose intolerance or meta­
bolic alkalosis. The diagnosis is confirmed by the finding of ele-
vated hormone levels, often expressed as the aldosterone–renin
ratio. Sometimes, selective venous sampling with radiological
guidance is necessary. Preoperative treatment of hypertension
should include potassium-retaining diuretics (e.g. spirono-
lactone) because profound postoperative hypokalaemia may
otherwise occur.
Cushing’s syndrome may cause a multitude of preoperative
problems (Table 4). Frequently, all of these are present and
patients can present a major anaesthetic challenge, even after
the problems have been optimized. There should be a high index
of suspicion for Cushing’s syndrome when clinical features are
present, but confirmation of the diagnosis is by the dexametha-
sone suppression test. If this indicates Cushing’s syndrome,
further tests are necessary to establish whether the problem is
a pituitary-dependent one or a primary adrenal one. Surgery is
usually unilateral but may occasionally be bilateral.
297 © 2008 Elsevier Ltd. All rights reserved.
 Endocrinology
Features of Cushing’s syndrome of relevance to the
anaesthetist
• Hypertension, often associated with left ventricular hypertrophy
• Diabetes mellitus
• Fluid retention with hypokalaemia
• Truncal obesity, often associated with obstructive sleep apnoea
• Fragile skin with easy bruising
• Proximal myopathy
Table 4
The laparoscopic approach to surgery, as usual, eases the
postoperative period but may cause surgery to be relatively pro-
longed; 3–5 hours would be the standard range and appropriate
precautions should be taken regarding temperature maintenance,
pressure areas, etc. As always, the effects of pneumoperitoneum
on the circulatory system must be considered. The usual position
is lateral or semilateral, so particular care with positioning may
be necessary in Cushingoid patients because of their large size
and fragile skin.
The anaesthetic management of these patients is that of
­relatively prolonged laparoscopic surgery. Invasive monitoring
is appropriate for selected cases. It is rarely necessary in Conn’s
syndrome but more frequently required in Cushing’s syndrome
with its attendant problems of diabetes, fluid retention and refrac-
tory hypertension. Similarly, admission to a high-dependency
area postoperatively depends on the individual case and local
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:7
arrangements. Patients with uncomplicated Conn’s syndrome
can normally be managed on a standard surgical ward, whereas
those with a ‘full house’ of Cushingoid features would usually
benefit from a period in a high-dependency area. Postoperative
ventilation is rarely required.
Postoperative analgesia after laparoscopic surgery is straight-
forward. As usual, the surgeons should be encouraged to use
generous local anaesthetic infiltration around port sites. Patient-
controlled analgesia is then satisfactory, and is required for
24–48 hours. If open surgery is used (e.g. because of difficult
laparoscopic access), postoperative epidural analgesia may be
considered, although in the author’s opinion it has little added
value in these cases.
Postoperative hormone supplementation is rarely required after
surgery for Conn’s syndrome. It is obviously required after any
bilateral surgery and frequently after unilateral surgery in Cush-
ing’s syndrome because the remaining, previously suppressed,
adrenal gland will not resume normal activity immediately. The
advice of an interested endocrinologist is recommended.
Conclusions
Surgery for endocrine disease is a specialized area requiring an
understanding of the basic sciences governing the endocrine sys-
tem. From the organizational viewpoint, there is a need for close
collaboration among surgeon, anaesthetist and endocrinologist.
In particular, preoperative preparation and postoperative man-
agement demand a team approach, in which each member is
aware of the others’ roles. ◆
298 © 2008 Elsevier Ltd. All rights reserved.