Anesthesia in a patient with multiple endocrine abnormalities. Case report.

Background And Objectives: Insulinoma is the most common pancreatic endocrine tumor and it can be associated with multiple endocrine neoplasia (MEN). This is a report on a patient with multiple endocrine abnormalities, who did not fulfill the criteria of known syndromes (MEN) and the clinical-anesthetic particularities that influenced the anesthetic management. CASE REPORT A 23-year old female patient with episodes of hypoglycemia difficult to control, associated with Cushing's disease and prolactinoma without symptoms of pituitary compression and with normal thyroid and parathyroid. Investigation found a retroperitoneal mass of unknown origin which in face of the clinical presentation raised the hypothesis of insulinoma. The patient also referred to be a Jehovah's Witness. Biopsy of the mass by video-laparoscopy and enucleation of the insulinoma were proposed. On physical exam the patient was overweight, had protruding teeth, she was classified as Mallampati 3 and had symptoms of sleep apnea. Laboratorial exams revealed hematocrit 58%. Pre-anesthetic medication consisted of oral midazolam (7.5 mg) and clonidine (200 microg). Fentanyl (150 microg), clonidine (90 microg), propofol (150 mg) and pancuronium (8 mg) were used for anesthetic induction and she was intubated without intercurrences. Central venous access and invasive blood monitoring were instituted. Intravenous infusion of D5W with electrolytes was instituted and capillary glucose levels were monitored every 30 minutes, which did not demonstrate any episodes of hypoglycemia during the surgery. The patient remained hemodynamically stable even during the pneumoperitoneum. She developed postoperative episodes of hypoglycemia, which motivated the re-operation.

Conclusions: This case is unique due to the presence of multiple endocrine abnormalities and the particularities of the surgical-anesthetic management. Intraoperative monitoring is mandatory during removal of an insulinoma to avoid incomplete tumor resection. Multiple challenges in one patient demand the knowledge, by the anesthesiologist, of each obstacle and its interactions in order to devise strategies to control them.