What are the recommended perioperative management strategies for a 60-year-old male with HTN, type 2 DM, dyslipidemia, hypothyroidism, and a previous total thyroidectomy due to micropapillary thyroid cancer, scheduled for an open adrenalectomy for a left suprarenal complex mass?

Perioperative Management for Open Left Adrenalectomy in a Complex Patient

Immediate Preoperative Priorities

Your plan is appropriate with critical additions needed: this patient requires stress-dose hydrocortisone coverage, aggressive potassium repletion, and meticulous hemodynamic monitoring given the high risk of intraoperative hypertensive crises and postoperative hypotension associated with adrenal mass resection. 1

Hydrocortisone Stress Dosing

• Hydrocortisone 100mg IV prior to OR, then 100mg IV Q8 hours for at least 3 doses is mandatory for all patients with autonomous cortisol secretion or suspected primary hyperaldosteronism undergoing adrenalectomy 1
• Continue stress-dose steroids until hemodynamically stable and able to tolerate oral intake, typically 24-48 hours postoperatively 1

Hypokalemia Correction

• Target serum potassium >4.0 mEq/L before surgery to reduce risk of perioperative arrhythmias 1
• Your plan of KCl 20 mEq in 100cc PNSS over 4 hours for 2 cycles is reasonable, but recheck potassium after each infusion and continue supplementation until normalized 1
• Patients with primary hyperaldosteronism commonly require 80-120 mEq total potassium replacement preoperatively 1

Blood Pressure Management Strategy

Continue all antihypertensive medications up to and including the morning of surgery EXCEPT the thiazide component 1

• Continue amlodipine 10mg, carvedilol 6.25mg, and telmisartan 80mg on morning of surgery 1
• Hold hydrochlorothiazide on morning of surgery to avoid exacerbating hypokalemia and volume depletion 1
• Never abruptly discontinue beta blockers or clonidine perioperatively as this causes potentially harmful rebound hypertension 1

Intraoperative Hemodynamic Management

Expected Hemodynamic Patterns

Anticipate severe hypertensive episodes during tumor manipulation (systolic BP >200 mmHg in 30-45% of cases) followed by profound hypotension after adrenal vein ligation 2, 3

Monitoring Requirements

• Arterial line placement is mandatory before induction for beat-to-beat blood pressure monitoring and frequent blood gas sampling 1
• Maintain MAP 60-65 mmHg minimum during surgery, individualized to patient's baseline (may need MAP >70 mmHg given chronic hypertension) 1
• Consider central venous access for vasopressor/inotrope administration and goal-directed fluid therapy 1

Vasopressor/Antihypertensive Strategy

• Have norepinephrine infusion prepared and ready as first-line vasopressor for post-resection hypotension (occurs in 30% of cases within 6 hours) 1, 2
• Prepare short-acting IV antihypertensives (nicardipine, clevidipine, or esmolol) for intraoperative hypertensive crises during tumor manipulation 1
• Preoperative 24-hour urinary VMA levels and total daily prazosin dose predict hypotension risk—higher levels correlate with more severe postoperative hypotension 2

Glycemic Management

Perioperative Glucose Control

Target blood glucose 140-180 mg/dL (7.7-10 mmol/L) throughout the perioperative period using variable rate insulin infusion 1

Medication Adjustments

• Hold gliclazide once NPO (already in your plan—correct) 1
• CRITICAL: Discontinue dapagliflozin (SGLT2 inhibitor) immediately—it should have been stopped 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis 4
• Continue Apidra sliding scale but transition to IV insulin infusion if NPO >8 hours or glucose >180 mg/dL 1
• Monitor capillary blood glucose every 1-2 hours intraoperatively and every 2-4 hours postoperatively while NPO 1

Hypoglycemia Risk

Monitor for hypoglycemia up to 12 hours postoperatively (occurs in 15% of adrenal tumor resections, with one case reported at 12 hours post-op) 2

Thyroid Hormone Management

• Continue levothyroxine 150mcg on morning of surgery 1
• Post-thyroidectomy patients are thyroid hormone-dependent and interruption risks myxedema 5

Fluid Management

Goal-Directed Fluid Therapy

Use goal-directed fluid therapy with cardiac output monitoring to optimize cardiac index ≥2.2 L/min/m² 1

• Your D5NSS at 100cc/hr is reasonable for maintenance, but adjust based on dynamic parameters (stroke volume variation, pulse pressure variation) rather than fixed rates 1
• Use balanced crystalloids preferentially over normal saline to reduce risk of hyperchloremic acidosis 1

Postoperative Monitoring Protocol

Duration and Intensity

Plan for 24-48 hours of intensive monitoring in ICU or step-down unit 3

• All hypotensive episodes occur within 6 hours of surgery 2
• Hypoglycemia may occur up to 12 hours postoperatively 2
• Recheck serum potassium 4-6 hours post-op (already in your plan—correct) 1

Risk Stratification for Extended Monitoring

This patient has high-risk features requiring full 48-hour intensive monitoring: 3

• Preoperative MAP >100 mmHg (patient's baseline ~100 mmHg)
• Resistant hypertension on 4 medications
• Primary hyperaldosteronism with severe hypokalemia
• Complex adrenal mass with lymphadenopathy

Blood Pressure Monitoring

Expect persistent hypertension in 33% of cases at 3 months post-op—risk factors include age >60 years and diabetes mellitus (both present in this patient) 2

Critical Pitfalls to Avoid

1. DO NOT discontinue beta blockers or reduce dose preoperatively—continue carvedilol at full dose to prevent rebound hypertension 1

2. DO NOT delay surgery for blood pressure control alone unless systolic BP >180 mmHg or diastolic >110 mmHg 1

3. DO NOT use NSAIDs postoperatively given chronic kidney disease risk (BUN 44, Cr 1.78 suggests CKD Stage 3) 4

4. DO NOT assume hemodynamic stability after 6 hours—hypoglycemia can occur up to 12 hours post-op 2

5. DO NOT forget to adjust hydrocortisone dosing based on postoperative course—may need continuation beyond 3 doses if hypotensive 1

Additional Recommendations

Anesthesia Considerations

• Use multimodal analgesia with acetaminophen and avoid NSAIDs 1
• Implement PONV prophylaxis with multimodal approach (ondansetron + dexamethasone) given high-risk surgery 1
• Maintain normothermia with active warming devices 1

Renal Protection

This patient has significant renal dysfunction (Cr 1.78, BUN 44, proteinuria) requiring: 4

• Maintain MAP ≥70 mmHg given baseline hypertension to preserve renal perfusion 4
• Avoid nephrotoxic agents 4
• Monitor urine output hourly 1

Postoperative Transition

• Restart oral antihypertensives when tolerating PO, but expect need for dose reduction or medication discontinuation if primary hyperaldosteronism is cured 2
• Transition to oral hydrocortisone taper once hemodynamically stable, typically starting 48-72 hours post-op 1
• Resume metformin only after confirming stable renal function and adequate oral intake 1