Extreme Cortisol Pumping: Pumping During Surgery

A few days ago, I had my 10th surgery. This one was different as opposed to the previous nine. For the first time I was permitted to wear my pump during the procedure.


So how did it go?


This was a fairly quick, laparoscopic abdominal surgery. Patients without comorbidities are usually back home in a few hours. Since I have adrenal insufficiency and some signs of pheochromocytoma, they did keep me a little longer as a precaution. 

Speaking of precautions, if you have adrenal insufficiency you MUST speak to your surgeon, endocrinologist and anesthesiologist about your steroid plan for surgery. Everyone needs to be on the same page. I can’t tell you how many times I’ve heard adrenal insufficient patients say, “oh the anesthesiologist knows what to do” DO NOT EVER MAKE THAT ASSUMPTION! They do tend to keep solu-cortef in the operating room, but that doesn’t mean they will dose it correctly. Some anesthesiologists deviate from the standard of care and come up with their own plan using less steroid. They think they’re doing you a favor, when really they are unknowingly endangering your life and hindering your recovery. DO NOT LEAVE THIS UP TO CHANCE! Make sure you’re on the same page!


As soon as surgery was mentioned, I made my concerns clear. I knew there would need to be special precautions because of the risk of adrenal crisis or hypertensive episodes due to pheo. I spoke to my surgeon and endo about this as well as two anesthesiologists. I had to have more tests than the norm in order to be cleared for surgery. I had to have any possible pheo activity blocked by taking blood pressure medication for a couple months. At this hospital they don’t assign an anesthesiologist until the night before the procedure. This makes communication a challenge, but by the time I actually met her, pretty much everyone including the nurses had already heard about my steroid plan and pheo concerns. When I discussed it with her, she had already heard my plan and was thankfully in agreement. I would receive 100mg of solu-cortef before and after the procedure and keep my pump running.

https://www.addisons.org.uk/files/file/4-adshg-surgical-guidelines/


This is where I made a mistake. I planned on running a straight 10mg/hr during the procedure. However I forgot to program that profile into my pump. I programmed it in pre-op and realized my settings only allowed me to go as high as 8mg/hr. I didn’t want to edit my settings at the last minute, so I programmed 8mg/hr. That would have worked just fine except I FORGOT TO SWITCH OVER TO THAT PROFILE. Yes, it is all well and good to program a profile, but you have to actually “run” said profile for it to work. Oops! So during the procedure I was running my normal every day basal program of 30.2mg/daily. 🤦‍♀️


I woke up being wheeled into recovery. My abdomen hurt so bad. They gave me IV pain medication, but the relief began to fade after a couple minutes. They gave me another dose. Then I watched the nurse give me 100mg of solu-cortef. 15 minutes later I was moved to a regular room. That’s when I realized there was a problem. The IV pain meds had worn off already. My pain was uncontrolled. I felt nauseous, but the nurse would not give me any oral pain medication until I ate something. I had a couple spoonfuls of pudding and felt sick. I was given IV zofran with minimal effect. Still sick. Every IV medication I’d been given seemed to metabolize way too fast. This has always been the case for me, and it’s the main reason I had to switch to the cortisol pump to begin with. 
There’s a familiar and unpleasant feeling I get when my cortisol isn’t sufficient. It’s an uneasy, almost panic feeling where I’m keenly aware that something isn’t right and I’m increasingly desperate to find relief or escape. It’s more like a primal instinct, “Something is wrong, help me!” I’ve unfortunately felt this enough times to realize it was cortisol related. I realized then my pump was still set on the measley 30mg profile. I immediately switched it to the 8mg/hr profile that I had programmed in pre-OP. The problem is it takes a while for pump rates to build your blood cortisol level. For whatever reason my body did not keep those 100mg IV solu-cortef boluses in my system very long. So I had to suffer while my rates caught up. Meanwhile the nurse had given me a couple doses of pain pills, and IV phenergan. Phenergan only helped the nausea for 5 minutes or so, but thankfully it made me extremely sleepy. I was able to sleep through the misery and give my pump some time to do its thing. A few hours later the nurse came in to check on me, by then the pain meds were working and my pump was kicking butt. I was still pretty knocked out from the phenergan, but I felt well enough to get dressed and go home. My nausea was gone and my appetite had returned. Yay for proper steroid dosing!


Friends, I can’t tell you enough how much sufficient steroid dosing will make or break a situation. Especially a high stakes situation like a surgery. It’s amazing how fast I went from utter misery in the hospital, to eating a sandwich at home. Steroids ya’ll! They’re a big deal! I stepped down to my 84mg/daily “sick” basal profile and kept it there until late evening. Note: your ability to lower your stress dose will be a case by case situation and depends on what type of surgery you had, how long it was and how invasive it was. Pain control is a major factor. Stay on top of your pain medication schedule. Do not let your meds lapse or try to suffer through it. This will increase your body’s cortisol need, hinder your ability to taper your steroid dose, and potentially prolong your recovery. You need sufficient steroid dosing to get pain under control and you need your pain meds to keep your cortisol need under control. They go hand in hand, don’t skimp on one or the other. 


Quick PSA: When you’re running high rates. YOU WILL need to change your inset more often. Pumping during surgery and recovery sounds pretty convenient compared to stress dosing with pills, and it was, but what I did not mention is all the stress that kind of volume puts on an infusion site. My site was leaking by bed time, which I totally expected to happen. This is EVEN MORE true if you run 2:1 dilution ratio in your pump because you are pumping twice the volume than those on 1:1 ratio. So yes, stress dosing and sick dosing with the pump is easier and more effective than pills, but DO NOT NEGLECT YOUR SITE! Don’t wait for it to start leaking either! When you’re ill/recovering your body needs cortisol the most, this is not the time to wait around for a site failure! I’ve changed my site DAILY while recovering from this procedure.


I’ve had 2 previous surgeries as a pumper, but the medical teams for those procedures were not familiar  with, or keen on the idea of pumping during surgery, and I didn’t push them for it. After my experience pumping during this latest procedure, I am going to push for my pump every time. Infection risk is minimal, it’s less than that of the actual surgery itself. The continuous delivery of the pump is ideal for recovery and superior to IV bolusing dosing only, especially since hospitals seem to think bolusing once every 8-12 hours is going to work fine. Its miserable. Continuous delivery is where it’s at! One day they’ll get with the times I hope.


At the time of writing it’s been nearly 48 hours since my surgery. I’m back on my normal profile plus a 200% increase (double dosing). My energy is good and my pain is well controlled as long as I keep up the pain medication schedule. My biggest problem at the moment is remembering not to over do it. I’m tempted to clean house, go on a walk, etc, and I dont feel like resting like I should. Steroid dosing makes a world of difference, and the pump makes this a much smoother experience. Just don’t neglect your infusion site or your pain meds! Happy healing friends!

❤Michelle

UPDATE: Please check out thecortisolpump.com a comprehensive and research based guide to cortisol pumping!

Pre-Surgery Update

I’m actually doing really well right now. I feel really good and I’m so grateful for that!

I came back from a follow up trip to the National Institutes of Health in July. During this trip we found out that all of my tumors have grown, and I have several new metastases to the liver. Most of these tumors and the liver metastases are likely spread of medullary thyroid cancer. One tumor on my left hip is a pheochromocytoma metastasis. That tumor must be removed before anything else can be addressed.

So I’ve been really busy preparing for my trip to NIH (again) in just a few days. I’ll be there for two weeks this time. One week of pre-op testing, then surgery, then a week of observation and recovery before I can fly home.

Honestly, I’ve been stressed and afraid up until very recently. You would think after so many surgeries I wouldn’t be afraid, but sometimes knowing what to expect is both a blessing and a curse.

In the past week or so I’ve come to feel more prepared and optimistic. The meds they put me on to prepare for surgery were tough at first, but I’m adjusting well. I still don’t love that I’ll be away from my family and my home for two weeks, but I know I can get through this. Then today at church we had an amazing service that talked about being rooted in love (and as we know, perfect love drives out fear), which was a very timely message for me. All through worship and the sermon I felt like God was speaking to me. I also found out the communion crackers are gluten free, so I got to participate in communion for the first time! It was pretty exciting for me, and I’m feeling more confident about this trip now. I know this will not go how I expect. It never does. That just seems to be God’s way. Whether it’s better or worse than I imagine, it will still be okay, because God will be with me.

I’m looking forward to getting all this behind me. It won’t be my last surgery, but it will be one less tumor, and one more important step in this journey. I’m not sure exactly how this is going to go, but I’m hopeful for an uncomplicated surgery and smooth recovery. I hope that before long I’ll be back to feeling as good as I do right now.

Thank you to everyone that has listened to me and given me encouragement. It really helps.

Michelle

https://youtu.be/sIaT8Jl2zpI

How to Beat Cancer

I hope that when I die no one ever says I lost my battle with cancer. To lose to cancer would be to give in to the fear, to die before you’re dead.

Every day I wake up, and every breath I take is beating cancer. Every moment of joy is a win over cancer. Rejecting fear, and living a life full of love and gratitude is a victory against cancer.

Though I can’t be cured, I hope to keep “beating” cancer for years to come. Fighting isn’t all about treatments and surgeries. It means living courageously on your own terms.

Cancer can take so much from us, but we can still refuse to lose. What we do with the time we’re given is how we truly beat cancer.

Life Without Pheo? A Post Surgery Update

It’s been 2 months since my surgery. For anyone just tuning in, I have a genetic condition called MEN2a. I’ve had it my whole life, but wasn’t diagnosed until 2011. Since then I’ve had six surgeries related to MEN2a. Most of them have been to remove pheochromocytomas

This surgery was different. This time I wasn’t messing around. I went straight to the leading experts in the country, at the National Institutes of Health, so that I can maybe have these mean little tumors gone for good. I was naive in the past. After every surgery I foolishly thought I would be cancer and tumor free. I’ve come to realize over time that it’s not so easy. Unfortunately MEN2a will be a part of my life forever. The good news, both pheochromocytomas and medullary thyroid cancer tend to be slow growing tumors relative to other cancers. The bad news is that both have very few effective treatment options. The typical chemo and radiation are ineffective with these, and would do more harm than good. Really the most effective treatment is surgery. It’s traumatic, and it’s hard on the body, but as long as my tumors pop up in operable places, that’s the best case scenario.

So are my tumors finally gone? 

I’m not going to jump any conclusions like I did after past surgeries. God willing, all the pheochromocytomas are gone for the time being. That was the goal of the surgery. However, as has happened in the past, they can grow back. What I can say, is that I’m feeling very well. I haven’t had any of the painful pheochromocytoma symptoms. My heart isn’t acting crazy lately. My 8 inch abdominal incision is healing well and I’m in very little to no pain. I can’t express what a good feeling this is!

Will this be my last surgery?

Probably not. I still have medullary thyroid cancer metastases. The plan currently is to return to the National Institutes of Health for further evaluation and to come up with a treatment plan. I really don’t know how they will choose to handle this. The good news is that at this time, the MTC isn’t causing any symptoms. I can sort of trick myself into forgetting it’s there. 

I will go back to NIH in 3-6 months for more testing. In the mean time, I need to follow up with an endocrinologist locally. This is not an easy task for someone like me. I can’t see just any endocrinologist. While they are all technically “specialists” there are very few that have expertise in a condtion like MEN2a. To further comlicate things, there is literally no one else with the combination of rare conditions I have, plus using a treatment method as unheard of as the cortisol pump. I’m deep in uncharted territory here. I’ll have to settle for a doctor that is experienced with most of these conditions, and willing to learn more about the rest. Currently, I’m scheduled to see an endocrinologist at UT Southwestern. Unfortunately, they do not work with my insurance company, and my primary doctor was unwilling to help me work out a solution with them. So it looks like I will be paying out of pocket to be seen and treated here. Yikes! I have no idea how I’m going to afford it, but if God guided me here he will make a way.

💕Michelle 

Finally Some Answers: An Update

image

I made it through another long distance appointment! I’m pretty pleased that I’ve been able to manage these trips as well as I have. They take a lot of careful preparation, but I can do it as long as I plan for every scenario. Adapting and working around challenges seems to be just as important as getting better in the chronic illness game.

I met with a surgical oncologist and we discussed my imaging results. At my last appointment, with my other doctor, I left more confused and worried than I started. This latest appointment finally brought some answers, so here is what we see going on so far:

Medullary Thyroid Cancer appears stable, there are some lymph nodes to watch, and labs still look on the higher side, but no tumors are seen right now.👍

-The nodule inside my right lung does not appear to be a tumor.👍

-There are 2 tumors:

1. A pheochromocytoma on the right adrenal bed. This is where my adrenal used to be, and where I have had pheo occurances previously. Left side is still clear after 5 years.
2. A tumor in the paraspinal region, behind my lung. We don’t yet know what kind of tumor this is. There will be more imaging to investigate.

-We talked about the “the suspicious liver lesion” mentioned in the MRI summary, which he says is actually the same pheo BEHIND the liver. The liver itself looks okay. That’s not a separate tumor. 👍

So instead of a bunch of vague, scary info, I now know more about what we’re dealing with. Next step is MIBG imaging of the tumors. This is a test specifically for pheochromocytomas. This will tell the doctors if the tumor in my chest is also a pheo, and should rule out any other pheos hiding.

The surgeon told me these are both in operable areas. Of course I’m not excited about the idea of more surgeries, but still, that is very good news. Both sites are operable and manageable. So the adventure begins again, surgery with adrenal insufficiency is going to be a new experience for me, but we’ll cross that bridge when we get there. Surgery is my best chance for long term management of the tumors that come with MEN2a, and best chance at a normal life expectancy. I know I’ve said this every time, but fingers crossed that maybe, just maybe, these tumors will stop coming back this time. I know I’ll always have to monitor and manage my MEN2 the rest of my life, but I still would like to stop this cycle of surgery every year. Maybe a few years off this time?

Overall, I’m happy with how the appointment went, and should have my MIBG imaging scheduled soon!

Stay healthy my friends!

💕Michelle