Overview of the Patient’s Condition
Question:
Discuss about the Perioperative Care of Retroperitoneal Laparoscopic.
Susan Summer is a 40 year old female having 3 children and has been diagnosed with type 2 diabetes. Susan has been admitted in to the hospital due to some changes in her appearance due to Cushing syndrome, caused due to benign tumor on the right adrenal gland. Susan has been admitted to the ED for a laparoscopic right adrenalectomy. This analysis will help to identify the aetiology and the pathophysiology of the patient’s condition. This will also help to provide the underlying pathophysiology of the underlying condition of the patient in the post operative period. The paper also aims to discuss about the specific priorities of care for Susan and the possible referrals.
According to the case study Susan was suffering from Cushing syndrome. Discussing about the pathophysiology of Cushing syndrome is a disorder that is caused when the body has got higher level of cortisol hormone. Cortisols are released by adrenal tumors (Aksakal et al., 2013). Non cancerous tumors such as Adrenal adenomas and macronodular hyperplasia that causes enlargement of the adrenal gland and the over production of the cortisol. Excess glucocorticoid production can be because of primary adrenal lesions or ACTH producing pituitary adenoma (Allolio, 2015). The production of the cortisol occurs by a precise chain of events. At first the hypothalamus of the brain sends corticotropin releasing hormone to the pituitary gland (de La Villéon et al., 2015). The CRH helps the pituitary to release the adrenocorticotropin hormone which in turn stimulates the adrenal glands. The adrenal glands respond by secreting cortisol (Lacroix et al., 2015). The Cushing syndrome can be ACTH dependant or ACTH independent. If it is ACTH independent then it can be caused by the overproduction of the glucocorticoids due to the adrenal adenoma (de La Villéon et al., 2015). The ACTH level in the ACTH dependant Cushing syndrome is less because of the negative feedback control to the corticotrophin cells of the pituitary from high level of serum cortisol (Lacroix et al., 2015). The most common signs and symptoms involve moon faces, supraclavial fat pads, truncal obesity which is clearly seen in Susan, purple striae and facial plethora. Other features are weight gain, excess hair growth in women, fatigue and hypertension (Lacroix et al., 2015).
The clinical manifestations of Susan can be linked to the pathophysiology of the clinical condition in many ways. Some of the risk factors related to Cushing syndrome are obesity and the case study reveals that the BMI of Susan is quite high. Obesity in Susan can be linked with excess adrenocorticotrophic hormone, cortisol or the CRH levels (Husebye et al., 2012). Normally cortisol accumulates in the body and replaces the consumed fats and the carbohydrates, and this is how it maintains the BMI (Lacroix et al., 2015). But in case of Susan the cortisol level is high in the body which would require more carbohydrates. Hence excess cortisol metabolizes the food even there is no requirement (Iacobone et al., 2015). Hence excess fats get accumulated in different parts of the body. One of the symptoms of Cushing syndrome is the high blood sugar level. DM in CS is caused due to the insulin resistance and impaired insulin secretion by the excess of glucocorticoids (Husebye et al., 2012). Insulin resistance is brought about the excess of GC by interfering with the insulin signaling cascade, which ultimately results in low uptake and synthesis of glycogen. Excess GC also leads to excess lipolysis. The augmentation in the level of the amino acids further impairs the insulin signaling pathway, this ultimately diabetes (Mazziotti et al., 2013).
Cushing Syndrome: Causes and Symptoms
Susan has undergone a laparoscopic right adrenalectomy under general anesthesia and has been transferred to the ward. Susan’s respiratory rate is 30 breaths per minute, blood pressure of about 160/90 mm Hg, a temperature of 35.0°C and a pulse of 128 bpm. She is having a pain score of 0/10. The normal respiratory rate should range between 12-20 breaths/ minute and the pulse rate should lie between 60-100 beats per minute and the temperature should be within the range 36.0-38.0 degree. In the post operative period the temperature should remain between 36.5-375°C. In a patient with laparoscopic adrenalectomy the pain scores should remain within 0-3. The vital signs of Susan reveal that the pain has been well managed in Susan and she is not experiencing any pain (Pivonello et al., 2012). In female the normal blood pressure should be <110/<80. Oxygen saturation should be more than 98%. The high blood pressure in Susan is absolutely due to the Cushing syndrome and the inflammatory response caused by the surgery. Pain medications might have effect on the cardiac output which can attribute to the increased pulse rate in Susan. According to the case study the temperature of Susan is well controlled. Susan’s body mass index and diabetes has to be considered while addressing her health modifications. It should be kept in mind that patients having diabetes and high BMI faces many health complications after the surgery (Farkas et al., 2012). The high respiratory rate of Susan may be due to hypoxaemia that normally causes when the body compensates for more oxygen for eliminating the metabolic acidosis. The urine output in Susan is also considerably decreased.
The post operative care should require and ABCDE management namely airway, breathing, circulation, drips, drains, dressings and the extras (Nieman et al., 2015).
At first it is essential to check the airway of the patient, if there are any blockages or if the patient is having any problem to swallow or breath. It is necessary to ausculate the lung and check for the breathing sounds. Susan’s high respiratory rate can be managed by keeping her in the supine position, according to the health status of Susan (Tang et al., 2015). This would help to lessen the pressure on the abdomen and increase the lung expansion. It is necessary to assess the circulation by measuring the pulse rate, blood pressure, color, temperature, peripheral pulses. It is necessary to assess the drains (Tang et al., 2015). Susan was having a low drainage. Proper aseptic techniques should be undertaken for preventing the infections. Pain can be assessed by signs lie facial grimacing and other pain measurement tool.
Patients with laparoscopic adrenalectomy can feel frequently well with limited analgesics and are able to tolerate regular diet. The patient should be provided with urinary catheter. Spironolactone is immediately stopped after the removal of the tumor in patients for preventing hyperkalemia (Tang et al., 2015). The patient is given chronically elevated levels of steroid hormones that will help to suppress the normal functioning of the contra lateral glands. Stress dose steroids should be started after the operation. Patients having moderate pain can be given non-narcotic pain medication like ibuprofen and Tylenol. A light bandage with a clear plastic covering will be placed over the incision. A BP of 160/90 means that Susan had been suffering from stage 1 hypertension which can be linked to the Cushing’s disease. In order to maintain the high BP Angiostenin converting enzymes can be given. A pulse rate of 128 bpm signifies that the pulse rate is high and can be controlled by medicines like propanolol. All the medications have to be given as per proper dosages and timing. The post operative management involves the application of the steroid supplementation after the adrenalectomy until the recovery of the suppressed hypothlamic pituitary adrenal axis. Hydrocortisone can be given intravenously. Adrenalectomey can have increased risk of venous thromboembolic disease, which can be minimized by the application of the medicines and mechanical antothrombotic prophylaxis (Park et al., 2015).
Clinical Manifestations and Pathophysiology of Cushing Syndrome
In the post operative period the nurses will be monitoring the vital signs frequently, collect information, process them, identify if the patient is having complications. It is the duty of the nurses to prepare a proper diet plan for Susan (Autorino et al., 2016). If hypokalemia is present then food rich in high potassium should be included. Laboratory test of glucose levels and electrolytes should be frequently monitored. It should be remembered that removal of the adrenal gland causes adrenal insufficiency, due to which hypovolemic shock and Addisonian crisis might occur (Park et al., 2015). Cortisol can be administered on the post operative period for replacing the insufficient hormone levels. The body temperature, WBC count and the amount of the wound drainage should be assessed. The dressings should be changed or cleaned by using aseptic techniques (Park et al., 2015).
It is necessary to involve multidisciplinary team members in order to address the needs of Susan and helps in speedy recovery in Susan. The case study reveals that Susan was suffering from obesity and diabetes and hence a dietician is required for giving support to the diet and the lifestyle of the patient. An endocrinologist can be consulted with since the patient had undergone removal of an adrenal tumor. Furthermore the case study reveals the Susan has got three children under the age of ten years. Any kind of surgery contributes to physical as well as emotional burden hence Susan may require a home nurse to help her out with daily chores or her children. It is also evident that Susan drinks frequently to cope up with work stress. Hence an alcohol management regimen can be chalked out in collaboration with the home nurse and a social care worker. The social care worker can help Susan in case of any financial requirement until Susan is capable of resuming her work.
Adrenalectomey can bring about complications if the patient is elderly, obese and have diabetes. Proper ABCDE management, application of proper medications, regular monitoring of the vital signs, and employing of a proper multidisciplinary team is required to provide a comprehensive care to Susan. A proper pre-operative, intra-operative and post operative management can bring about better outcomes in Susan.
References
Aksakal, N., Agcaoglu, O., Barbaros, U., Tukenmez, M., Dogan, S., Kilic, B., … & Mercan, S. (2015). Safety and feasibility of laparoscopic adrenalectomy: What is the role of tumour size? A single institution experience. Journal of minimal access surgery, 11(3), 184.
Allolio, B. (2015). Extensive expertise in endocrinology: adrenal crisis. European journal of endocrinology, 172(3), R115-R124.
Autorino, R., Bove, P., De Sio, M., Miano, R., Micali, S., Cindolo, L., … & Kim, F. J. (2016). Open versus laparoscopic adrenalectomy for adrenocortical carcinoma: a meta-analysis of surgical and oncological outcomes. Annals of surgical oncology, 23(4), 1195-1202.
de La Villéon, B., Bonnet, S., Gouya, H., Groussin, L., Tenenbaum, F., Gaujoux, S., & Dousset, B. (2016). Long-term outcome after adrenalectomy for incidentally diagnosed subclinical cortisol-secreting adenomas. Surgery, 160(2), 397-404.
Farkas, D. T., Moradi, D., Moaddel, D., Nagpal, K., & Cosgrove, J.M. (2012). The impact of body mass index on outcomes after laparoscopic surgery. Surgical Endoscopy (Vol. 26(4), pp 964-969). DOI: 10.1007/s00464-011-1978-5
Husebye, E. S., Allolio, B., Arlt, W., Badenhoop, K., Bensing, S., Betterle, C., … & Kämpe, O. (2014). Consensus statement on the diagnosis, treatment and follow?up of patients with primary adrenal insufficiency. Journal of Internal Medicine, 275(2), 104-115.
Iacobone, M., Citton, M., Scarpa, M., Viel, G., Boscaro, M., & Nitti, D. (2015). Systematic review of surgical treatment of subclinical Cushing’s syndrome. British Journal of Surgery, 102(4), 318-330.
Lacroix, A., Feelders, R. A., Stratakis, C. A., & Nieman, L. K. (2015). Cushing’s syndrome. The lancet, 386(9996), 913-927.
Mazziotti, G., Formenti, A. M., Frara, S., Maffezzoni, F., Doga, M., & Giustina, A. (2017). Diabetes in Cushing Disease. Current diabetes reports, 17(5), 32.
Nieman, L. K., Biller, B. M., Findling, J. W., Murad, M. H., Newell-Price, J., Savage, M. O., & Tabarin, A. (2015). Treatment of Cushing’s syndrome: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 100(8), 2807-2831.
Park, K. S., Kim, J. H., Ku, E. J., Hong, A. R., Moon, M. K., Choi, S. H., … & Kim, S. Y. (2015). Clinical risk factors of postoperative hyperkalemia after adrenalectomy in patients with aldosterone-producing adenoma. European journal of endocrinology, 172(6), 725-731.
Pivonello, R., De Leo, M., Cozzolino, A., & Colao, A. (2015). The treatment of Cushing’s disease. Endocrine reviews, 36(4), 385-486.
Tang, C., Xu, Z., Yi, X., Li, P., He, H., Zhang, Z., … & Zhou, W. (2015). Fast track surgery vs. conventional management in the perioperative care of retroperitoneal laparoscopic adrenalectomy. International journal of clinical and experimental medicine, 8(9), 16207.
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