What management is required after adrenalectomy in a child to prevent adrenal insufficiency?

Management After Adrenalectomy in Children

After adrenalectomy in a child, lifelong glucocorticoid replacement is required, with fludrocortisone added only in cases of bilateral adrenalectomy or primary adrenal insufficiency. 1, 2

Immediate Postoperative Management

Following adrenalectomy, children require stress-dose glucocorticoid coverage:

• Administer hydrocortisone 2 mg/kg IV every 4 hours after major surgery like adrenalectomy, or use continuous infusion if the child is unstable 3, 2
• Monitor blood glucose hourly until enteral intake resumes, as children with adrenal insufficiency are at risk for hypoglycemia 3
• No child with adrenal insufficiency should be fasted for more than 6 hours 3

Tapering Protocol

Once the child is stable and tolerating oral intake:

• Double the normal maintenance dose of oral hydrocortisone for 48 hours after establishing enteral intake 3, 1
• Taper to standard maintenance doses over up to one week if recovery is uncomplicated 1, 2
• The rapid tapering over 1-3 days is appropriate for uncomplicated cases, while more complex recoveries may require up to a week 1

Long-Term Maintenance Therapy

For Bilateral Adrenalectomy (Complete Adrenal Insufficiency):

• Hydrocortisone 15-25 mg daily in split doses (typically given as higher dose in morning, lower in afternoon to mimic physiological rhythm) 1
• PLUS fludrocortisone 50-200 μg as a single daily dose for mineralocorticoid replacement 1
• This represents primary adrenal insufficiency requiring both glucocorticoid and mineralocorticoid replacement 1

For Unilateral Adrenalectomy:

• If performed for Cushing's syndrome or other unilateral pathology, the contralateral adrenal may be suppressed 4
• Temporary glucocorticoid replacement is needed until the remaining adrenal recovers function (typically weeks to months) 4
• Lifelong replacement is NOT required if the remaining adrenal gland recovers adequate function 4
• Fludrocortisone is NOT needed as the remaining adrenal provides mineralocorticoid function 1

Critical Monitoring Considerations

• Monitor blood pressure and electrolytes regularly, particularly in children requiring fludrocortisone 1
• Watch for signs of adrenal insufficiency during tapering: fatigue, weakness, nausea, vomiting, hypotension 1
• Some children may require higher doses than standard calculations suggest, particularly if there are comorbidities affecting absorption 4

Patient and Family Education

Essential counseling points:

• The child must carry medical identification indicating steroid dependence 5
• Families must understand "sick day rules" - doubling or tripling hydrocortisone doses during febrile illness, vomiting, or significant stress 3
• An emergency injection kit should be available at home, with a trained caregiver who can administer it 3
• Increased dosing is required during times of stress (trauma, surgery, severe illness) both during treatment and potentially for up to a year after stopping therapy 5

Common Pitfall to Avoid

The most critical error is premature discontinuation of glucocorticoid therapy. Option B (stop immediately) would be catastrophic and could precipitate life-threatening adrenal crisis 1, 2. The answer depends entirely on whether the adrenalectomy was unilateral or bilateral - bilateral requires lifelong therapy, while unilateral may allow eventual discontinuation once the remaining gland recovers 1, 4.