Anaesthetic Challenges and Considerations in a Patient Undergoing Adrenalectomy: A Case-Based Review

Introduction:

Adrenalectomy presents unique anaesthetic challenges due to the diverse functional status of adrenal tumors, potential for profound hemodynamic instability and complex perioperative endocrine implications. Adrenalectomy is performed for both functional and non-functional adrenal lesions. Functional tumors such as pheochromocytoma, cortisol-secreting adenomas, and aldosteronomas pose significant anaesthetic risks due to hormonal hypersecretion. Even non-functional adrenal masses may be associated with significant perioperative challenges due to anatomical proximity to major vascular structures, risk of haemorrhage and potential adrenal insufficiency post-resection.

Case Description:

A 32-year-old female presented with left flank pain, fever and vomiting for five days. She had a past history of tuberculosis involving the right knee joint, for which she underwent right knee arthrodesis. There was no history of hypertension, diabetes mellitus or endocrine disorders.

Contrast-enhanced computed tomography (CECT) abdomen revealed:

• A well-defined lesion measuring 2.3 × 2.3 × 2.4 cm arising from the right adrenal gland.
• An irregular thick-walled peripherally enhancing lesion measuring 4.2 × 6.5 × 6.9 cm in the left adrenal gland, suggestive of an inflammatory or infective pathology.

The patient was planned for left adrenalectomy.

Preoperative Anaesthetic Considerations:

1. Functional Assessment of Adrenal Mass:

All adrenal masses must be evaluated for hormonal activity prior to surgery. Even in the absence of overt clinical signs, biochemical screening is mandatory to rule out:

• Pheochromocytoma (plasma free metanephrines, urinary catecholamines)
• Cushing’s syndrome (serum cortisol, dexamethasone suppression test)
• Primary hyperaldosteronism (plasma aldosterone-renin ratio)

Failure to identify a catecholamine-secreting tumor may result in catastrophic intraoperative hypertensive crises.

2. Evaluation of Infective Etiology:

Given the patient’s history of tuberculosis and presence of a thick-walled lesion, differential diagnosis included adrenal tuberculosis or abscess. Tubercular involvement of the adrenal gland may lead to adrenal insufficiency. Baseline serum electrolytes and cortisol levels are crucial.

3. Airway and Positioning Concerns:

Right knee arthrodesis limits positioning options. Careful padding and positioning are required during lateral decubitus positioning to avoid nerve injury and pressure sores.

4. Volume Status and Electrolytes:

Vomiting for five days may lead to dehydration, hypokalemia, and metabolic alkalosis. Preoperative optimization includes:

• Correction of electrolyte imbalances
• Adequate hydration
• Acid-base correction

5. Sepsis and Systemic Inflammatory Response:

Fever and imaging findings suggest possible infection. Sepsis screening, blood cultures, inflammatory markers, and antibiotic coverage are essential prior to induction.

Intraoperative Anaesthetic Management:

1. Monitoring:

Standard ASA monitoring plus:

• Invasive arterial blood pressure monitoring
• Central venous access (if large mass or suspected pheochromocytoma)
• Urine output monitoring
• Temperature monitoring

2. Induction:

Goals during induction:

• Avoid sympathetic stimulation
• Maintain hemodynamic stability
• Prevent catecholamine surges (if pheochromocytoma suspected)

Preferred agents:

• Etomidate or propofol for induction
• Opioids (fentanyl) for blunting stress response
• Non-depolarizing muscle relaxants

Avoid ketamine in suspected catecholamine-secreting tumors.

3. Hemodynamic Challenges:

If Pheochromocytoma:

• Severe hypertension during tumor manipulation
• Sudden hypotension after adrenal vein ligation

Vasodilators (nitroprusside, nitroglycerin) and short-acting beta blockers should be readily available.

If non-functional tumor:

• Blood loss due to proximity to inferior vena cava
• Hypotension due to haemorrhage

4. Surgical Approach Considerations:

Robotic/ Laparoscopic adrenalectomy introduces additional concerns:

• Effects of pneumoperitoneum
• Increased intra-abdominal pressure
• Reduced venous return

Open adrenalectomy may involve larger fluid shifts and greater blood loss.

Postoperative Considerations:

1. Hemodynamic Monitoring:

Patients require close observation in a high-dependency unit or ICU.

2. Adrenal Insufficiency:

Signs include:

• Hypotension
• Hyponatremia
• Hyperkalemia
• Hypoglycemia

Perioperative steroid supplementation may be required, particularly if bilateral disease or preoperative suppression is suspected.

3. Pain Management:

Multimodal analgesia preferred:

• Paracetamol
• NSAIDs (if renal function adequate)
• Opioids
• Regional techniques (e.g., epidural) where appropriate

4. Infection Control:

Given possible infective pathology and tuberculosis history, continued antimicrobial therapy and evaluation for systemic spread are necessary.

Discussion:

Adrenalectomy poses anaesthetic challenges primarily related to endocrine physiology and potential hemodynamic instability. Even small adrenal lesions can be hormonally active. Comprehensive endocrine workup is non-negotiable before surgery.

In this patient, differential diagnoses include:

• Non-functional adrenal adenoma
• Adrenal tuberculosis
• Adrenal abscess
• Pheochromocytoma (biochemically silent possibility)

The presence of fever and a thick-walled lesion raise suspicion of infective pathology, particularly in a patient with prior tuberculosis.

The anaesthesiologist must be prepared for:

• Hypertensive crises
• Massive haemorrhage
• Adrenal insufficiency
• Sepsis-related hemodynamic instability

A multidisciplinary approach involving endocrinology, surgery, infectious disease specialists, and anaesthesia is essential for optimal outcomes.

Conclusion:

Adrenalectomy requires meticulous preoperative endocrine evaluation, intraoperative hemodynamic vigilance and proactive postoperative monitoring. In patients with possible infectious adrenal pathology and previous tuberculosis, the risk of adrenal insufficiency and sepsis further complicates management. Individualized anaesthetic planning, invasive monitoring and preparedness for rapid hemodynamic fluctuations are the cornerstones of safe perioperative care.

References:

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Adrenal incidentaloma: Anesthetic management, the challenge and the outcome. Al-Hadhrami R M et al. Anesth Essays Res. 2011;5(2):217–223. Case report with literature review on adrenal incidentalomas and perioperative anesthesia issues.