Adrenalectomy through the Nurse's Eye

			Perioperative care of the laparoscopic adrenalectomy patient  OR Nurse 2013, November 2010 Expires: 12/31/2013

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Perioperative care of the laparoscopic adrenalectomy patient

Jennifer Dziuba-Pallotta BSN, RN, CNOR Vivian Akontoh-Kufour RN, CNOR Ravi Munver MD, FACS OR Nurse 2013 November 2010   Volume 4  Number 6  Pages 22 - 29

Laparoscopic adrenalectomy is the standard of care for removal of the adrenal gland. The advantages of a laparoscopic approach include decreased postoperative pain, shorter hospital stay, and improved cosmetic results. The perioperative nurse plays an integral role in the preoperative, intraoperative, and postoperative phases of surgery, and is crucial in facilitating positive patient outcomes. Figure. No caption available. Case study A healthy 37-year-old woman sought medical attention from her primary care provider for a chief complaint of frequent headaches. After a medical examination, she was diagnosed with hypertension and was prescribed oral antihypertensive medication. Four months later, the hypertension persisted and was poorly controlled despite multiple oral medications. Serum lab results revealed hypokalemia. The patient underwent a computed topography (CT) scan of the abdomen and pelvis, which revealed a 3-cm right adrenal mass. Further serum and urine chemistries confirmed the adrenal mass was a functional aldosterone-producing adrenal adenoma. The patient was referred to a urologist with expertise in laparoscopic surgery and scheduled to undergo a right laparoscopic adrenalectomy to treat her hypertension and hypokalemia. Introduction The adrenal glands are small retroperitoneal organs that are an integral component of the endocrine system. These organs secrete hormones essential for the body to regulate electrolytes, manage fluid balance, maintain normal BP, as well as help control the body's response to stress. They also play an important role in sexual development. There are several types of tumors that affect the function of the adrenal glands. Since the initial report on the laparoscopic approach for adrenalectomy in 1992, laparoscopic adrenalectomy has gradually become the standard of care for most conditions requiring surgical removal of the adrenal gland.1 Review of anatomy and physiology The adrenal glands are retroperitoneal organs located at the superior aspect of the kidneys bilaterally. The adrenal glands receive their blood supply from branches of the inferior phrenic artery, renal artery, and the aorta (see Location of the adrenal glands). Each adrenal gland consists of two independently functioning components, the adrenal medulla and the adrenal cortex. The adrenal medulla is located in the center of the gland and secretes catecholamines (epinephrine and norepinephrine). The adrenal cortex surrounds the medulla and is responsible for producing mineralocorticoids, glucocorticoids, and adrenal androgen hormones. The products secreted by the adrenal glands are influenced by pituitary gland activity. Indications for surgery Laparoscopic adrenalectomy is indicated for hypersecretory benign adrenal tumors or selected primary malignant adrenal tumors. Although the exact size of a nonsecreting adrenal tumor prompting surgical intervention remains controversial, most authorities agree that lesions greater than 4 to 5 cm should be removed due to the increased likelihood of malignancy. Smaller lesions are more often benign and can be followed radiographically.2 Functional adrenal adenomas that secrete hormones such as aldosterone and cortisol are among the most common indications for surgical excision of the adrenal gland. These benign tumors are considered optimal for laparoscopic excision due to their location and small size. Aldosteronomas secrete aldosterone and are characterized by severe-to-moderate hypertension as well as hypokalemia.3 The hypertension resulting from this tumor may not respond to medical intervention and therefore often requires surgical removal. Figure. Location of the adrenal glands A cortisol-producing adenoma is responsible for 30% of all Cushing syndrome cases. The majority of these tumors are benign; however, 15% are found to be malignant. Another adrenal tumor, pheochromocytoma, is a rare catecholamine-secreting tumor, which is benign in 90% of cases.4Due to the excessive amount of epinephrine and norepinephrine these tumors secrete, these patients are at higher risk for intraoperative cardiovascular complications such as severe hypertension and dysrhythmias. When surgically removing a pheochromocytoma, early ligation of the adrenal vein is crucial to prevent a sudden increase in BP due to manipulation of the adrenal gland.5 Although pathologic evaluation is the standard for establishing a definitive diagnosis, radiographic imaging is essential in the evaluation of an adrenal mass. CT scans with and without intravenous contrast are vital in assessing adrenal lesions. Magnetic resonance imaging scans are also commonly obtained in the evaluation of adrenal masses. This imaging study can provide additional information such as identifying adipose tissue within lesions and improve the identification of invasion into surrounding structures.2 Laparoscopy vs. open surgery There are several advantages to the laparoscopic approach as compared to open surgery. The traditional open adrenalectomy requires a large flank or subcostal incision to obtain adequate exposure of the adrenal glands. A large surgical incision increases the risk of wound infection, results in significant postoperative pain, and prolongs recovery time.1The increased pain experienced with this type of incision may result in decreased mobility and impaired respiratory effort during the crucial postoperative period, leading to a higher risk of pneumonia as well as deep vein thrombosis. There's also a potential for increased blood loss with the open technique. Laparoscopic adrenalectomy is performed through several small keyhole size incisions (5 to 12 mm), and offers benefits of decreased postoperative pain, shorter hospital stay, quicker recovery time, and improved cosmetic results.1 In addition, because the adrenal vessels are dissected under high magnification on a high-definition (HD) screen, there's the potential for minimizing blood loss. Studies have also shown that the laparoscopic approach is associated with a significantly lower overall complication rate as compared to the open procedure.1 Preoperative nursing care A complete history and physical examination is mandatory in the evaluation of a patient with an adrenal mass. A complete endocrinologic evaluation should include measurement of serum electrolytes, serum hormone levels, and urine levels of steroid hormones and their metabolites. The particular diagnostic blood work ordered by the physician will depend on the observed clinical signs and symptoms as well as the patient's history and physical examination.2 When the patient arrives at the hospital on the day of surgery, the nurse should perform an initial preoperative assessment as per the institutional policy. A large-bore intravenous line should be inserted and electrolyte imbalances such as hypokalemia should be corrected preoperatively.3 At a minimum, the patient should be typed and screened because of the potential for blood loss during surgery. Bowel preparation isn't mandatory for the procedure; however, it can be helpful to decompress the bowel to facilitate the laparoscopic approach.1 Consent for the procedure must be signed and witnessed. The surgical site must be verified with the patient and clearly marked with a surgical marker by the attending surgeon before the patient is transported to the OR. This is a crucial step to ensure that during the intraoperative "time-out," the entire surgical team visualizes the site marked on the skin and agrees that the correct side has been selected.6 As with any surgical procedure, the RN should educate the patient as to what to expect during the intraoperative and postoperative phases. This discussion should include intravenous lines, arterial lines, sequential compression devices, an indwelling urinary drainage catheter, and other relevant issues. The RN should provide reassurance to the patient, encourage questions, and remain with the patient during the induction of anesthesia. Before the patient is brought to the OR, adequate positioning supplies need to be available and prepared including pillows, axillary roll, arm support device, padding materials, gel pad, and surgical tape (seeEssential supplies and equipment for laparoscopic adrenalectomy). Specialty equipment such as a laparoscopy insufflator, video tower, and appropriate thermal energy generators should be pretested. An experienced perioperative nurse knows that any laparoscopic procedure has the potential for elective or emergent open conversion due to bleeding, unanticipated organ injury, or failure to progress as in the case of excessive intra-abdominal adhesions. Appropriate instrumentation and supplies necessary for laparotomy should be readily available in the room, but may be kept unopened and uncounted unless their use is required. Upon arrival to the OR, the circulating nurse will interview and identify the patient. At least two patient identifiers are used, and may include: medical record number, name, and date of birth.6 The informed consent should include the surgical procedure, correct side, correct site, date, surgeon signature, patient signature, and witness signature. Because anatomically there is a right and a left adrenal gland, it's imperative for the patient to confirm the correct laterality (right or left side) of the diseased gland. As per The Joint Commission, the operative site needs to be marked while the patient is awake and alert, and before sedative medication is administered.6 A thorough preoperative nursing assessment should include N.P.O. status, allergies, medical history, previous surgery, metal implants or jewelry, loose or removable teeth, and the presence of contact lenses. After the patient is secured to the OR table with a safety belt, antithrombotic stockings and knee- or thigh-high sequential compression devices are placed on the lower extremities, to prevent venous stasis and reduce the risk of deep vein thrombosis and pulmonary embolism.7Prophylactic I.V. antibiotics should be administered within 60 minutes of the initial skin incision.8 After the induction of general anesthesia, the patient is endotracheally intubated and an orogastric tube is placed to decompress the stomach. An arterial pressure line may be established for hemodynamic monitoring. An indwelling urinary drainage catheter is inserted by either the circulating nurse or surgeon to decompress the bladder. The anesthesia provider avoids administering nitrous oxide to prevent bowel distension, which may limit exposure of the adrenal gland.9 Intraoperative nursing care For the perioperative nurse, proper positioning is one of the key responsibilities to protect the safety and skin integrity of the patient under anesthesia. The patient is placed on a beanbag or the surgeon might prefer large gel rolls placed behind the patient's back to help support the patient in the lateral decubitus position. To maintain proper alignment and stability during positioning, the patient must be moved by at least four team members. A gel pad is placed on the beanbag to help relieve pressure from the dependent hip and torso. The patient is placed in a modified lateral decubitus position with the affected side elevated 45 degree to 60 degree over the kidney rest portion of the operating table. The table may be gently flexed to increase the area between the iliac crest and costal margin.3 Pillows are placed between the legs and the dependant leg is flexed at the hip and knee for stabilization and alignment. The opposite leg is placed straight. The dependent leg should be well padded to prevent pressure on the common peroneal nerve. The dependent arm is placed on a well-padded arm board and secured with 3-inch cloth tape. The opposite arm is placed on a padded arm support device above the head or on several folded blankets or pillows, which is then secured to the OR table. The arms should never be abducted more than 90 degrees to prevent brachial plexus nerve injury.10 An axillary roll is placed 2 to 3 finger breadths below the dependant axilla to relieve pressure from the brachial plexus and facilitate adequate chest expansion. The ankles, knees, dependant hip, and shoulders need to be adequately padded to avoid neuromuscular damage. The patient is secured to the table with the safety strap, which may be reinforced with 3-inch tape over the hips and across the shoulders (see Positioning for right laparoscopic adrenalectomy). After positioning, the patient should be assessed for proper spinal alignment, tissue perfusion, and skin integrity. Also, pressure points on the dependent side, especially the ear, acromion process, iliac crest, greater trochanter, lateral knee, and malleolus, should be well padded to reduce risk of injury.11 The patient will also be placed on a lower or upper body warming device. After the patient is draped and just before the surgical incision is made, any member of the surgical team may initiate the time-out. This procedure requires the entire perioperative team to verify: * Correct patient identity Figure. Trocar placement for right laparoscopic adrenalectomy * Correct side and site markings * Correct patient position * Accurate procedure consent form * Relevant images and results are properly displayed or available * Antibiotic administration * Safety precautions based on patient history or medication.7 After the time-out has been verified and the entire surgical team verifies the mark indicating the correct side and site, surgery may proceed. A Veress needle is commonly used to insufflate the peritoneum. Generally, two or three 5 mm x 100 mm trocars and one 12 mm x 100 mm trocar are sufficient for performing laparoscopic adrenalectomy (see Trocar placement for right laparoscopic adrenalectomy). The first port is inserted at the umbilicus to accommodate the camera. Additional ports are placed at least 8 to 10 cm apart so that the surgeon's freedom of movement and operating space aren't restricted. With the laparoscopic approach, it's more difficult to dissect the adrenal gland because the surgeon doesn't have the ability to palpate the gland as in open surgery. Therefore, intraoperative ultrasonography can be used to aid in identifying the adrenal gland as necessary. The surgeon may utilize an atraumatic grasper, laparoscopic kittner, or suction irrigator in the nondominant hand and a dissecting instrument in the dominant hand. (See Common instrumentation for laparoscopic adrenalectomy). A variety of laparoscopic thermal energy devices are available. Ultrasonic shears are useful for colon mobilization and adrenal vein dissection. A laparoscopic bipolar vessel-sealing device has excellent hemostatic properties for performing the adrenal dissection. These devices have been shown to significantly decrease blood loss and operative time during adrenal dissection as compared to other thermal energy devices.12 An experienced circulating nurse and scrub person can often anticipate the surgeon's needs as they closely follow the steps of the procedure (see Surgical steps for laparoscopic adrenalectomy). The scrub person will stand on the opposite side of the primary surgeon to allow easy communication and facilitate instrument exchanges. Laparoscopic instruments are placed on a mayo stand with the handles facing the surgeon to expedite transfer to the surgeon's hands. During the procedure, the circulating nurse monitors the level of the CO2 tank and has reserve tanks available. Hemostatic agents must be readily available for the surgical team should bleeding occur. The circulating nurse must be prepared with additional trocars or a hand-access device if requested by the surgeon. The adrenal glands are highly vascular and lie adjacent to many vascular structures such as the inferior vena cava and aorta as well as vascular organs such as the liver and spleen. The perioperative nurse must be vigilant to potential intraoperative complications at all times such as bleeding and bowel injury. Emergent conversion to an open operation can occur at any time, and open surgical instruments and supplies should be readily available. Bleeding is the most common complication during and after laparoscopic adrenalectomy, accounting for 40% of complications.13The next most common complication is injury to surrounding organs such as the liver, spleen, colon, pancreas, and diaphragm, accounting for less than 5% of all complications.2 At the completion of the procedure, the specimen is grasped and placed into a laparoscopic specimen retrieval bag (see Intraoperative view of right adrenal gland (center), located under the elevated liver (top of photo). The specimen is removed by extending the 12-mm trocar incision as necessary. The CO2 pneumoperitoneum is evacuated before incision closure to decrease postoperative bowel irritation that may lead to delayed return of bowel function. The 12-mm trocar site may be closed with a fascial closure device, and the skin incisions are closed with subcuticular sutures or skin staples. Figure. Intraoperative view of right adrenal gland (center), located under the elevated liver (top of photo) Postoperative nursing care The patient is usually extubated in the OR before transport to the postanesthesia care unit (PACU). The orogastric tube is removed at the completion of the procedure. A chemistry screen and complete blood cell count are obtained in the PACU. Because the adrenal glands play an integral part in stress responses and BP regulation, close monitoring of BP is necessary via an arterial line or BP cuff.1 Postadrenalectomy patients require close monitoring of electrolytes, especially potassium. The PACU RN must also monitor the patient closely for signs of acute hemorrhage.2 The PACU nurse assesses the patient's level of pain and medicates the patient for pain as ordered. Typically, the patient won't require patient-controlled analgesia (PCA) as would be needed with an open adrenalectomy. Due to the small laparoscopic incisions, patients are prescribed pain medications at regular intervals on an as needed basis. Patients are encouraged to ambulate shortly following surgery. The urinary drainage catheter is removed on the first postoperative day. A clear-liquid diet is started on the first postoperative day, and the diet is advanced as tolerated. Serum cortisol levels are evaluated to assure that no element of adrenal insufficiency requires supplementation. A patient undergoing a unilateral adrenalectomy may require temporary replacement of glucocorticoids. If bilateral adrenalectomy is performed, the patient will be placed on cortisol replacement permanently. Most patients are discharged on the first postoperative day.3 Follow-up with the surgeon is usually a few days to a week after surgery. Patients can generally return to unrestricted activity approximately 4 weeks after surgery. Toward positive outcomes Laparoscopic adrenalectomy is currently the standard of care for surgical removal of the adrenal gland. Perioperative nurses are integral team members that must demonstrate attention to detail and critical-thinking skills in order to facilitate positive patient outcomes. Essential supplies and equipment for laparoscopic adrenalectomy * Beanbag and gel pad (or) gel roll * Axillary roll * Support * Pillows * Padding materials * Safety strap * 3-inch cloth tape * Sequential compression devices * Ultrasound machine * Laparoscopy insufflator and video tower * Thermal energy devices - ultrasonic shears generator - bipolar vessel-sealing device generator - monopolar cautery generator Common instrumentation for laparoscopic adrenalectomy * Veress needle * 5 or 10 mm, 0 and 30 laparoscopic scope * 5 and 12 mm trocars * Laparoscopic ultrasonic shears * Laparoscopic vessel-sealing device * Laparoscopic shears * Laparoscopic right angle dissector * Laparoscopic grasping forceps * Laparoscopic ultrasound probe * Polymer or titanium hemostatic clips (5 and 10 mm) * Suction-irrigation device * Laparoscopic retrieval bag * Laparoscopic peanut Surgical steps for laparoscopic adrenalectomy Left laparoscopic adrenalectomy Step 1 Mobilization of colon, tail of the pancreas, and spleen Step 2 Exposure of renal vein and adrenal vein Step 3 Ligation and division of adrenal vein Step 4 Dissection of adrenal gland borders (inferior, medial, superior, and lateral) with ligation and division of adrenal arteries and accessory veins Step 5 Retrieval of adrenal gland Right laparoscopic adrenalectomy Step 1 Mobilization of liver Step 2 Exposure of inferior vena cava and adrenal vein Step 3 Ligation and division of adrenal vein Step 4 Dissection of adrenal gland borders (inferior, medial, superior, and lateral) with ligation and division of adrenal arteries and accessory veins Step 5 Retrieval of adrenal gland REFERENCES 1. Zacharias M, Haese A, Jurczok A, Stolzenburg JU, Fornara P. Transperitoneal laparoscopic adrenalectomy: outline of the preoperative management, surgical approach, and outcome. Eur Urol. 2006;49(3):448-459. [Context Link] 2. Kesler S, Disick G, Munver R. Laparoscopic adrenalectomy. In: Nakada SY, Hedican SP, eds. Essential Urologic Laparoscopy the Complete Guide. 2nd ed. New York, NY: Humana Press; 2010:253-266. [Context Link] 3. Brunt LM. Minimal access adrenal surgery. Surg Endosc. 2006;20(3):351-361. [Context Link] 4. Hanberg A. Management of clients with adrenal and pituitary disorders. In: Black JM, Hawks, JH, eds. Medical Surgical Nursing. 8th ed. St. Louis, MO: Saunders Elsevier; 2009:1040-1054. [Context Link] 5. Nagle GM. Gentourinary surgery. In: Rothrock JC, ed. Alexander's Care of the Patient in Surgery. St. Louis, MO: Mosby; 2007:467-551. [Context Link] 6. The Joint Commission. Accreditation program: hospital national patient safety goals. 2010.http://www.jointcommission.org/NR/rdonlyres/868C9E07-037F-433D-8858-0D5FAA4322F2. [Context Link] 7. Phillips N. Perianesthesia and procedural patient care. In: Berry and Kohn's Operating Room Technique. 11th ed. St. Louis, MO: Mosby; 2007:612-613. [Context Link] 8. SCIP Project information. Medqic. http://www.medqic/contentserver.[Context Link] 9. Phillips N. Anesthesia: techniques and agents. In: Berry and Kohn's Operating Room Technique. 11th ed. St. Louis, MO: Mosby; 2007:422-423. [Context Link] 10. Heizenroth PA. Positioning the patient for surgery. In: Rothrock JC, ed. Alexander's Care of the Patient in Surgery. 13th ed. St. Louis, MO: Mosby; 2007:155. [Context Link] 11. O'Connell MP. Positioning impact on the surgical patient. Nurse Clin North Am. 2006; 41(2):173-192. [Context Link] 12. Munver R, Lombardo S, Ilbeigi P. et al. Advances in the minimally invasive treatment of benign and malignant adrenal lesions: laparoscopic adrenalectomy using a novel vessel-sealing system-a combined experience. J Urol. 2006, 175(4); 347. [Context Link] 13. Grumbs AA, Gagner M. Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab. 2006; 20(3):483-499. [Context Link]

CE Collection

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Beyond pituitary surgery: Radiosurgery vs. Adrenalectomy vs Medical Treatment when Cushing’s disease persists or recurs

I found this presentation today.
It's for people like me who suffer from refractory Cushing's and want to understand all the options.

http://www.goodhormonehealth.com/forpatients/CUSHINGS-beyond%20surg-magic09jan11%5B1%5D-1.ppt

My health is a big part of my life

BOOM - more high cortisol results

One day of four received.

Test results from 10/31/2013

15.4  HIGH diagnostic midnight cortisol serum (n<5, diagnostic >7.5)

0.37 HIGH midnight saliva cortisol (n< 0.09)

10.8 HIGH 17-ohs (n 2-6)

17.4 ------ cortisol, free, urine (n 4-50)

MN Cortisol serum is DOUBLE the diagnostic value of 7.5.

Saliva cortisol is FOUR times the upper limit of normal.

17-hydroxycorticosteroids is also high, as it always is for me.

Free cortisol is normal, as it always is for me.

Adrenal Surgery Treatment & Management

I have read a lot about bilateral adrenalectomy in general terms. Now, it is time that I know the specifics. This articles goes into more detail about the surgery than others I have seen to date.

Some of you may not want to know what happens, some like me do. It is here if you want it. No graphic photos.

http://emedicine.medscape.com/article/443536-treatment#showall

Keto: It was fun while it lasted

I started Ketoconazole in August 2012 after having high midnight salivary cortisol, high midnight serum cortisol, and high urine 17-hydroxy-corticosteroids. Keto resolved some symptoms but not all. At best, I dropped and kept 15 pounds off. I felt less weak and average but still definitely not myself. The daytime drowsiness became unbearable by Spring 2013. I was falling asleep daily. It came across me suddenly, like narcolepsy. Dr F treated me with Ritalin two times a day. It kept me afloat.

In late Summer 2013, the FDA put stricter limits on the use of oral Ketoconazole. The European Union banned its use. Liver toxicity is such a concern that the FDA recommends weekly liver function tests?!  

--ENOUGH SAID--  

I side with the EU on this one. The EU bans many known endocrine disrupters years before the FDA even considers it: BPA in baby bottles, rGH in milk.  I'm not taking that Keto stuff anymore.  Cushing's has disrupted enough body systems on its own. I certainly don't want to lose liver function just trying to keep cortisol at bay. Keto wasn't a wonder drug for me! 

I knew I had to stop Keto. It was hard to give up the little sleep Keto did allow me to get some nights. I was afraid to stop taking it. Being so tired each day anyway, I just didn't know how I would manage on no sleep with unmitigated cortisol running through my veins all night.  After my pituitary MRI and CT scan of the adrenals in October 2013 were read as clear, I knew it was time to move on. Keto was only a crutch to avoiding the inevitable.  It was time to get seriously prepare for a BLA.  I stopped Keto, scheduled an appointment with my doctor, and began midnight testing. I had five high midnight cortisol serums right out of the testing gate. 

After just a week since speaking to my doctor last, I am very close to getting cleared for a BLA (just waiting for some lab results to trickle in). 

Thanks FDA for making a a difficult decision a little bit easier for me.

- Melissa 

FDA Puts Strict Limits on Oral Ketoconazole Use

http://cushieblog.com/2013/08/03/fda-puts-strict-limits-on-oral-ketoconazole-use/

Pituitary Disorders and the Family

	PNA Webinar Announcement
		Webinar: Pituitary Disorders and the Family Presented By Jamie L. Banker, Ph.D. Director of Counseling Psychology California Lutheran University   Seating is limited, register today!   Date: Friday, November 15, 2013 Time: 12:00-1:00 PM PDT After registering you will receive a confirmation email containing information about joining the Webinar.   Webinar Information Chronic illness systemically affects individuals and families, in that the illness impacts the whole system, rather than just the individual with the diagnosis. Health problems can create or exacerbate conflict within a family or support system (Ruddy, Borresen, & Gunn, 2008). This is also the case within families with a family member with an endocrine disorder. Historically, research on medical illness focused mainly on the identified medical patient, but recent literature shows an ever-growing interest in understanding the physical and mental toll those managing and caring for close relatives with a serious illness or disability (Feigin, Barnetz, & Davidson-Arad, 2008). Family systems theories have influenced this turn, as it becomes clear that focusing on a problem with one family member acknowledges only one part of the affected system. In this presentation Dr. Banker will talk about what is meant by the "family system," what is meant by "collaborative' and "integrated" care, Dr. Banker will identify ways pituitary disorders impact the family system, She will discuss ways family members can positively impact healing and learn what can be the role of a "family therapist" in helping families affected by a pituitary tumor or other endocrine disorder. Dr. Banker will also talk about her most recent research connecting the early childhood trauma and pituitary disorders.   Learning Objectives Learn about the primary effects of chronic and/or serious illness on the family Learn what is meant by the "family system" Learn what is meant by "collaborative' and "integrated" care Identify ways pituitary disorders impact the family system Learn ways family members can positively impact healing Learn what can be the role of a "family therapist" in helping families affected by a pituitary tumor or other endocrine disorder   Presenter Bio Jamie Banker is the Director of Counseling Psychology Masters program and Assistant Professor of Psychology at California Lutheran University in Thousand Oaks California. She is a Licensed Marriage and Family Therapist and has a special interest in integrated behavioral healthcare. She completed a clinical master's degree at University of San Diego and completed her doctoral degree at Virginia Tech. Dr. Banker was a doctoral intern at Dartmouth College Family Medicine Residency. Dr. Banker has worked in three integrated primary care practices as a therapist and a lecturer. She has published scholarly articles and a few book chapter on integrated healthcare. Now her focus is on training Marriage and Family Therapy students to work in integrated behavioral healthcare sites. She is an AAMFT approved clinical supervisor. Dr. Banker's research agenda centers on women's and family's health. It encompasses topics that are both underserved and burgeoning in the fields of psychology, marriage and family therapy, behavioral medicine, and public health. Dr. Banker's primary research interests are collaboration between family therapists and medical professionals, family health and training integrated care professionals. These interests all fall under the larger umbrella of improving individuals' overall healthcare. Her research agenda is focused on decreasing the gap between medical and mental health assessment and treatment. Dr. Banker's current research is on understanding postpartum depression and disorders of the endocrine system from a biopsychosocial model.

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New Chapter of my Life

Hey everyone! I've missed you all. It's not that I haven't. I just haven't even able to keep up on posting like I wish I could. I hope you will always understand why and forgive me.

Today, I'm back with a big update.

I now walk the final  steps towards BLA and a cure from Cushing's. 

After two non-curative transsphenoidal pituitary surgeries, I spent many months wondering what to do and just trying to manage my symptoms. That has become increasing difficult and almost impossible for me as the days and months wore on. 

I started ketoconazole in August 2012 with mixed results. I slept well sometimes but still would wake up at 4:00 am, a Cushie's witching hour.  I felt good at the beginning but it started to wear off.  I spent some hours in the ER on 10/10/12 as I faced severe symptoms of adrenal insufficiency. I needed IV saline and IV hydrocortisone when the injection of 100 mg of Solu-cortef my husband gave me at home wasn't working.  I lost 23 pounds but I felt weak, unfocused, irritable, and overwhelmed. My daytime drowsiness was worse than ever.  I complained to Dr F in June 2013 that I had narcolepsy; I would sit on the couch for only a few moments in the late morning or afternoon, and I would fall asleep instantly. This is after having sleeping six to eight hours. I would just pass out.

In the past few months, I've taken Ritalin at Dr F's suggestion, and it has worked to keep me awake during the day.  I take a long-acting dose in the am and a short acting dose in the early pm. 

I dropped the ketoconazole and a week later, I saw Dr F for an office visit last Monday. He said he needed recent tests before he could clear me for surgery. I tested every day and night until the early hours of Sunday morning.

Midnight cortisol serums

normal is less than 5

diagnostic is greater than 7.5

My results six nights in a row:

5.2, 16.1, 15.4, 8.8, 19.4, 10.8

I am pretty astonished. I had no idea I was high, much less this high. My high test value before was 12.8.   My cortisol has been so high at night that my body is producing zero cortisol during the day. In the past, before testing, my body has been getting only the 20 mg of morning Cortef that I took while I was on Keto and it wasn't enough. My body was unhappy probably because it had become accustomed to such high levels of cortisol. Any drop have me symptoms of adrenal insufficiency: nausea, diarrhea, loss of appetite, extreme fatigue, muscle pain, joint point, grouchiness. 

Now, I am pretty happy to have these test feathers in my rediagnosis cap.  I am waiting for results on four UFCs w/ 17OHS and five salivas taken during the same time period as the high midnight cortisol serums. I feel good that some will be high.  

I hope to be cleared for BLA within the week. There is no visible tumor on my pituitary. Even an exploratory third surgery is not wise, since my second neurosurgeon said surgery would "result in a guaranteed cerebrospinal fluid leak" based on the post operative tissue's location at the bottom of the gland. My doctor and I know that I am not a good fit for other medical therapies. It's BLA time.  I plan on having a BLA before the end of the year, since insurance pays 100% now.

I have done everything I can in the last six years as a Cushing's patient. I have done everything the medical community has required of me, and many things that should not be required:  guessing when to test, knowing what my body was feeling at every moment and what medication would best treat it, watching over every lab technician like a hawk, feeling guilty after outbursts of emotion towards my family and every time I missed family time so I could nap, even keeping up on refills of 15 medications and organizing a 31-day pill case, even when I wasn't sure I was feeling better from any of it. I have suffered in countless MRI machines that could barely hold my large frame but I made it through the hour with some anti-anxiety pills, pain meds, and a one moment at a time attitude.  

This is my road. This is my path. I accept it.  I feel relief and confidence. I am feeling peaceful and hopeful. 

Stay tuned as a march my way towards my cure from the cortisol beast. Thanks for sticking with me.

- Melissa 

BLA takes a Patient from Cushing's to Addison's

Adrenal crisis in treated Addison's disease: a predictable but under-managed event

1. Katherine White and
2. Wiebke Arlt1

1. Addison's Disease Self-Help Group,PO Box 1083, Guildford GU1 9HX
   
   ¹School of Clinical and Experimental Medicine, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham College of Medical and Dental Sciences, Edgbaston, Birmingham B15 2TT, UK

1. (Correspondence should be addressed to K White; Email:kgwhite@addisons.org.uk)

Abstract

Context Adrenal crisis is a life-threatening event that occurs regularly in Addison's patients receiving standard replacement therapy. Patient reports suggest that it is an underestimated and under-managed event.

Objective To assess the frequency of adrenal crisis in diagnosed patients and to understand the factors contributing to the risks of adrenal crisis.

Design We conducted a postal survey of Addison's patients in four countries, UK (n=485), Canada (n=148), Australia (n=123) and New Zealand (n=85) in 2003, asking about patients' experiences of adrenal crisis and their demographic characteristics. In 2006, a shorter follow-up survey was conducted in the UK (n=261).

Method The frequency and causes of adrenal crisis were compared across both surveys. Demographic data from the 2003 survey were analysed to establish the main variables associated with an elevated risk of crisis.

Results Around 8% of diagnosed cases can be expected to need hospital treatment for adrenal crisis annually. Exposure to gastric infection is the single most important factor predicting the likelihood of adrenal crisis. Concomitant diabetes and/or asthma increase the frequency of adrenal crises reported by patients.

Conclusion The endocrinologist has a responsibility to ensure that Addison's patients have adequate access to life-saving emergency injection materials and repeated, practical training sessions in how to use them, while the general practitioner plays a vital role as in arranging prompt emergency admissions.

Click through to read the full article on the European Journal of Endocrinology website.

http://m.eje-online.org/content/162/1/115.full

Patient Access to Current Medical Literature

File this one under Learn Something New Every Day.  To me, this is a BIG SOMETHING.

Doing research? Do you want to read a recent article? 

The Endocrine Society grants access to patients upon request.

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Please use this request for articles recently published in The Journal of Clinical Endocrinology & Metabolism, Endocrinology,Molecular Endocrinology, or Endocrine Reviews.

Note that all articles published more than 12 months ago back to 1997 are free to all online.

To receive your copy of the requested article, please provide the following information:

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NOTE

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Reading your Rx

I'm in the midst of updating my massive medication list, as I am going to see my Cushing's specialist today.  It occurred to me that after all these years of being sick, I still don't know how to read all the abbreviations on a prescription. Cushing's just won't allow me to commit some new things to memory, but thanks to Google, you and I can learn once these terms once and for all.

wikihow.com/Read-a-Doctor's-Prescription

SIGN THE PETITION: We deserve better than Solu Cortef

Cushies deserve a better emergency injectable device than the one option we have in Pfizer's Solu Cortef. This medication is used during an adrenal crisis, in an emergency (http://cushingsmoxie.blogspot.com/2011/12/my-friends-with-adrenal-insufficiency.html). 

There are just too many steps for me to follow while semi-conscious before getting the high dose of steroid that will save my life. 

There are just too many steps for my caregiver to follow when seeing me semi-conscious before giving me the high dose of steroid that will save my life. 

Meet Rachel. She is doing something about it.

This mom is fighting to make it happen. Rachel, a British mother, desperately wants her child and family to have an easier way to administer emergency cortisol injections--like Solu-Cortef for her 14 year old daughter with hypopituitarism. Her daughter doesn't make any cortisol and relies on replacement steroids, like Addison's patients or Cushies after pituitary surgery or bilateral adrenalectomies.

Please read their story and consider signing the petition.

If you live in the United Kingdom, please sign this petition:
http://you.38degrees.org.uk/petitions/for-cortisones-sake-give-steriod-dependents-the-life-saving-injection-they-need

If you live elsewhere in the world, please sign this petition via facebook:
https://m.facebook.com/rachelpeglersavinglivesforsterioddependants/about?notif_t=page_new_likes&__user=100000742731717

BLA "relatively safe and provides adequate success"

I have watched several close friends get bilateral adrenalectomies in the past few months and at least another hundred get BLAs since I learned I have Cushing's in 2007. 

I am ready to have mine. With my body at its weakest but my will at its strongest, I want to get on with the rest of my life. I want to see what happens next for me.

What a timely article filled with information I need to know right at this exact moment in my life.

While it is hard to know it at the time, hindsight shows that things always work out for me.

--m

• Home
 
• |2013 Archive 
• |October 2013
• |Ritzel et al. 98 (10): 3939

• Journal of Clinical Endocrinology & Metabolism
• Special Features

Outcome of Bilateral Adrenalectomy in Cushing's Syndrome: A Systematic Review

 Authors

1. Katrin Ritzel,
2. Felix Beuschlein,
3. Anne Mickisch,
4. Andrea Osswald,
5. Harald J. Schneider,
6. Jochen Schopohl and
7. Martin Reincke

1. Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, D-80336 München, Germany

1. Address all correspondence and requests for reprints to: Martin Reincke, M.D., Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstrasse 1, D-80336 München, Germany. E-mail:Martin.Reincke@med.uni-muenchen.de.

Abstract

Background: The outcome of bilateral adrenalectomy (BADx) in patients with Cushing's syndrome (CS) is not well characterized.

Methods: A literature search was performed with the search terms "bilateral adrenalectomy" or "total adrenalectomy" and "Cushing's" or "Cushing." Immediate and long-term outcomes after BADx in CS were analyzed using descriptive statistics (median [range]).

Results: From 549 screened publications, 37 studies met inclusion criteria (1320 patients, 82% having Cushing's disease [CD], 13% having ectopic CS, and 5% having primary adrenal hyperplasia). Surgical morbidity and mortality of BADx (23 studies, 739 patients) were 18% (6–31) and 3% (0–15), respectively. In patients with CD, surgical mortality was below 1%. Although residual cortisol secretion due to accessory adrenal tissue or adrenal remnants was found in 3–34% (5 studies, 236 patients), less than 2% had a relapse of CS. Symptoms of hypercortisolism (eg, hypertension, obesity, or depression) improved in the majority of the patients after BADx (7 studies, 195 patients). The number of adrenal crises per 100 patient-years was 9.3 (6 studies, 203 patients). Nelson's syndrome occurred in 21% (0–47) of the patients (24 studies, 768 patients). Mortality (23 studies, 690 patients) was 17% (0–88) at a follow-up of 41 months (14–294). Remarkably, 46% of the patients died in the first year after surgery. The median ages at death were 62 years (CD) and 53 years (ectopic CS).

Conclusion: BADx is relatively safe and provides adequate success. Excess mortality within the first year after surgery suggests that intensive clinical care for patients after BADx is warranted.

Footnotes

• For editorial see page 3974

• Abbreviations:

  BADx

  bilateral adrenalectomy

  BAH

  bilateral adrenal hypercortisolism

  CD

  Cushing's disease

  CS

  Cushing's syndrome

  ECS

  ectopic CS

  NS

  Nelson's syndrome

  QOL

  quality of life

  TSS

  transsphenoidal surgery.

• Received February 21, 2013.
• Accepted August 5, 2013.

• Copyright © 2013 by The Endocrine Society

Yes, we need the Solu-Cortef pen to be easier to dispense. My growth hormone Nutropin is so easy to do. The injectable that saves our life should be just as easy. I'm signing the petition. Will you?

Brimscombe mum's plea for injection pen which could save her little girl's life

6:02pm Monday 30th September 2013

By Hayley Mortimer

MUM Rachel Pegler has issued a heartfelt plea to SNJ readers to back a petition for health bosses to create an injection pen which could save her little girl's life.

Brimscombe schoolgirl Molly, 14, suffers from a rare condition called hypopituitarism, which can be fatal if levels of the hormone cortisol drop too low and she does not receive an injection in time.

She cannot leave the house without a life-saving kit that contains a syringe, needles and vials of hydrocortisone and her teachers at Thomas Keble School have been trained to give the jab.

Rachel is urging medical bosses to create an 'epi-pen' for this type of illness, which would enable Molly to administer her own injection in an emergency.

She has launched an online petition to get the issue raised in Parliament, which has already attracted more than 2,000 signatures.

"We currently have a very outdated style injection," said Rachel, an artist and illustrator.

"I worry that when alone and close to unconscious my little girl would not even be able to take the top off the glass tube.

"An injection pen could mean life or death."

Cortisol is a chemical hormone produced by the body to manage stress by providing a boost of blood sugar.

When Molly becomes stressed or unwell she is unable to produce enough cortisol and has to rely on extra steroids, which she takes three times a day.

If she is sick or suffers any trauma or injury she needs an emergency injection and hospital treatment.

Molly, who has an older brother Josh, 19, and younger sisters Poppy, 10, and Primrose, one, also has other health problems, which affect her immune system.

"Ultimately I would like my little girl to finally have a normal life," said Rachel.

"Molly is the most cheerful lovely girl. She loves writing scripts and fiction.

"It is such a strain on all of us when she is poorly, we all find it very hard.

"Molly has gone through so much and deserves the knowledge that no mistakes will be made in saving her life in an emergency situation."

To sign the petition go to http://tinyurl.com/o2dwoxp

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Cortisol: The Hormone Maverick

Not too many things about Cushing's make me laugh. This lecture title did.

Hypercortisolemia: When a Good Hormone Goes Bad

http://umhsheadlines.org/02/hypercortisolemia-when-a-good-hormone-goes-bad-oct-4/

Help PCPs Know What How to "Treat" a Cushing's Patient

treat  

[treet] 

verb (used with object)

1.

to act or behave toward (a person) in some specified way: to treatsomeone with respect.

2.

to consider or regard in a specified way, and deal with accordingly: to treat a matter as unimportant.

3.

to deal with (a disease, patient, etc.) in order to relieve or cure.

This article is targeted to primary care physicians, often the first stop on a patient's path to diagnosis. Some patients face uninterested doctors with little medical curiosity. I did. You likely did. It is my hope that these physicians listen to their patients and begin to test for this not-so-rare-but-rarely-diagnosed disease. Primary Care Physicians must learn how to treat (1) Cushing's patients as much as they learn to treat (3) us.  This article offers guidelines for this front-line group. -- M

When to think Cushing's syndrome in type 2 diabetes

http://www.familypracticenews.com/news/diabetes-endocrinology-metabolism/single-article/when-to-think-cushings-syndrome-in-type-2-diabetes/7e58da25eede65a1fb4da2a45934b679.html

Pituitary damage an unexpected war wound

I have noticed the news stories and court cases of enlisted soldiers beating and killing their loved ones after returning from Iraq and Afghanistan. I have often wondered if soldiers who become ultra aggressive and harm loved ones are suffering from pituitary damage, since many outside the situation describe personality changes and aggression.  The article below suggests it is probable that blast-related injuries can definitely cause pituitary dysfunction. This is just another way that soldiers of war are changed forever.

In addition, I remain sad for the stateside significant others -- mostly wives, girlfriends -- who are lost to violence at the hands of loved ones from any cause related to any war. 

--Melissa 

Pituitary damage an unexpected war wound
http://www.latimes.com/la-me-pituitary-damage-20130801,0,579258.story

Excerpts:

[quote]"Tests revealed damage to Spires' pituitary gland. It was a rare finding in the military, but that may be because few doctors have been looking for it.

Emerging evidence suggests that pituitary problems may be going undiagnosed in victims of blast-related brain injuries, the defining wounds of the recent wars.

The symptoms often overlap, perhaps explaining why some patients do not fully recover and offering hope that hormone replacement therapy might help in some cases.

Trying to get a handle on the problem, the Pentagon last year issued guidelines to its doctors to screen for hormone irregularities when symptoms persist after concussions — the mildest and most common form of traumatic brain injury, or TBI.

The pea-sized pituitary gland secretes nine hormones that help regulate metabolism, sexual function, blood pressure and other vital processes. Housed in a bony pocket in the skull, it hangs from the base of the brain by a strand of neurons and blood vessels.

Experts long have known that serious head trauma can disrupt the blood supply and nerve connections. Over the last decade, the same damage has been documented in people who suffered concussions in car crashes and sports accidents. Only in the last few years did scientists begin to look specifically at the risk from blasts."[\endquote]