What are the endocrine management recommendations for a patient undergoing adrenalectomy?

Perioperative Endocrine Management for Adrenalectomy

For patients undergoing adrenalectomy, perioperative glucocorticoid supplementation is essential, with hydrocortisone 100 mg IV at induction followed by continuous infusion of 200 mg/24h to prevent potentially fatal adrenal crisis. 1

Preoperative Assessment

• Identify the type of adrenal pathology requiring surgery:

  • Primary adrenal insufficiency
  • Secondary adrenal insufficiency
  • Cushing's syndrome
  • Aldosterone-producing adenoma
  • Pheochromocytoma
  • Other adrenal tumors

• Evaluate current glucocorticoid therapy:

  • Patients on chronic steroid therapy (prednisolone ≥5 mg daily or equivalent for >1 month)
  • Patients with known adrenal insufficiency
  • Patients with suspected adrenal suppression

• Laboratory assessment:

  • Baseline cortisol and ACTH levels
  • Electrolytes (particularly potassium in aldosteronoma)
  • Blood glucose

Intraoperative Management

For All Adrenalectomy Patients:

• Adult patients: Administer hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24h 1, 2

• Pediatric patients: Hydrocortisone 2 mg/kg at induction followed by continuous IV infusion based on weight 1, 2:

  • Up to 10 kg: 25 mg/24h
  • 11-20 kg: 50 mg/24h
  • Over 20 kg (prepubertal): 100 mg/24h
  • Over 20 kg (pubertal): 150 mg/24h

• Alternative if continuous infusion not possible: Hydrocortisone 50 mg IV/IM every 6 hours 1

Postoperative Management

Immediate Postoperative Period:

• Continue hydrocortisone 200 mg/24h by IV infusion while NPO 1
• Monitor for signs of adrenal crisis:
  • Hypotension
  • Nausea/vomiting
  • Abdominal pain
  • Confusion
  • Hypoglycemia

Transitioning to Oral Therapy:

• Once able to take oral medications:
  • Double the usual replacement dose of hydrocortisone for 48 hours
  • For major surgery, continue double dose for up to a week 1
  • Example: If usual dose is 10-5-5 mg, increase to 20-10-10 mg

Special Considerations:

For Bilateral Adrenalectomy:

• Patients will require lifelong glucocorticoid and mineralocorticoid replacement 3
• Higher risk of acute adrenal crisis (9% hospitalization rate in long-term follow-up) 3
• Educate patients on "sick day rules" for stress dosing

For Unilateral Adrenalectomy:

• For aldosterone-producing adenomas:

  • Monitor potassium levels (hypokalemia typically resolves immediately) 4
  • Blood pressure may take up to 6 months to normalize in 31% of patients 4

• For Cushing's syndrome with bilateral adrenal hyperplasia:

  • Unilateral adrenalectomy may be sufficient in selected cases 5
  • Monitor for recurrence and need for contralateral adrenalectomy

Long-term Follow-up

• For complete adrenalectomy: Lifelong replacement therapy with education on:

  • Sick day rules (doubling doses during illness)
  • Emergency hydrocortisone injection training
  • Medical alert bracelet/card

• For partial adrenalectomy:

  • Monitor morning cortisol levels
  • Perform ACTH stimulation test to assess adrenal reserve
  • Gradually taper supplemental steroids if adrenal function recovers

Common Pitfalls to Avoid

1. Failure to recognize adrenal insufficiency: If in doubt about the need for glucocorticoids, they should be given as there are no long-term adverse consequences of short-term administration 1, 2

2. Inadequate dosing: Surgical stress requires 5-fold increase in cortisol production (approximately 100 mg/day) 1

3. Abrupt discontinuation: Never stop glucocorticoids suddenly; always taper according to clinical response

4. Ignoring patient knowledge: Patients with long-standing adrenal insufficiency are often well-informed about their condition and medication needs 1

5. Glycemic control: Children with adrenal insufficiency are particularly vulnerable to glycemic disturbances and require frequent blood glucose monitoring 2

By following these guidelines, you can significantly reduce the risk of perioperative complications and adrenal crisis in patients undergoing adrenalectomy, improving both short-term outcomes and long-term quality of life.