What is the management of suspected adrenal insufficiency during surgery?

Management of Suspected Adrenal Insufficiency During Surgery

For patients with suspected adrenal insufficiency during surgery, immediately administer hydrocortisone 100 mg intravenously followed by continuous infusion of hydrocortisone at 200 mg/24 hours to prevent adrenal crisis and reduce mortality. 1

Recognition of Intraoperative Adrenal Insufficiency

Symptoms of adrenal insufficiency during surgery may include:

• Unexplained hypotension refractory to fluid resuscitation and vasopressors 2
• Electrolyte abnormalities, particularly hyponatremia and hyperkalemia 2
• Unexplained fever 3
• Altered mental status (if patient is awake) 2
• Increased eosinophil count on laboratory testing 4

Immediate Management Protocol

For Adults:

1. Immediate hydrocortisone administration:

   • Administer hydrocortisone 100 mg IV bolus immediately 1
   • Follow with continuous IV infusion of hydrocortisone 200 mg/24 hours 1
   • Alternative if continuous infusion not available: hydrocortisone 50 mg IV/IM every 6 hours 1

2. Fluid resuscitation:

   • Administer 0.9% saline 1000 ml within the first hour 3
   • Continue fluid resuscitation as needed based on hemodynamic parameters 3

For Children:

1. Immediate hydrocortisone administration:
   • Administer hydrocortisone 2 mg/kg IV/IM immediately 1, 5
   • Follow with continuous IV infusion based on weight:
     • Up to 10 kg: 25 mg/24 hours 1, 5
     • 11-20 kg: 50 mg/24 hours 1, 5
     • Over 20 kg (prepubertal): 100 mg/24 hours 1, 5
     • Over 20 kg (pubertal): 150 mg/24 hours 1, 5

Post-Crisis Management

1. Continue steroid coverage:

   • Continue IV hydrocortisone while patient is nil by mouth 1
   • Once enteral route is available, transition to oral glucocorticoids at double the usual maintenance dose for 48 hours 1
   • For major surgery or complicated recovery, continue double doses for up to a week 1

2. Monitor for response:

   • Improvement in blood pressure should occur within hours of hydrocortisone administration 4
   • Patients with functional hypoadrenalism show significant improvement in vasopressor requirements within 24 hours of hydrocortisone administration 4

Special Considerations

• Patients on chronic steroids: Patients receiving prednisolone equivalent ≥5 mg for 4 weeks or longer require stress-dose coverage according to the same protocol as those with known adrenal insufficiency 1, 5

• Mineralocorticoid replacement: For patients with primary adrenal insufficiency, add fludrocortisone once enteral feeding is established 1, 5

• Dexamethasone alternative: For major surgery, dexamethasone 6-8 mg IV may be used instead of hydrocortisone and will provide coverage for 24 hours 1

Common Pitfalls to Avoid

• Delayed recognition: Failure to consider adrenal insufficiency in patients with refractory hypotension can lead to increased mortality 4, 3

• Inadequate dosing: Underdosing steroids during major surgical stress can precipitate adrenal crisis 3

• Abrupt discontinuation: Tapering is essential when transitioning from stress-dose steroids back to maintenance therapy 2

• Overlooking at-risk patients: Remember that patients on chronic inhaled corticosteroids may also have hypothalamic-pituitary-adrenal axis suppression requiring stress-dose coverage 5

• Failure to continue mineralocorticoid: Patients with primary adrenal insufficiency require both glucocorticoid and mineralocorticoid replacement 5, 2

Recent evidence suggests that traditional stress-dosing protocols may provide more glucocorticoids than necessary 6, but until more definitive studies are available, the current guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK should be followed to ensure patient safety 1.