Anesthesia and Glucocorticoid Abnormalities
Clinical Manifestations
- Etiology
- Exogneous administration of steroids
- Hyperfunction of adrenal cortex (e.g., adrenocortical adenoma)
- Non-pituitary tumor secreting ACTH (ectopic ACTH syndrome)
- Cushing's disease (pituitary adenoma hypersecreting ACTH)
- Signs (Cushing's syndrome)
- muscle wasting and weakness
- osteoporosis
- central obesity
- abdominal striae
- glucose intolerance
- hypertension
- mental status changes
- Correct fluid and electrolyte abnormalities (hypokalemic metabolic alkalosis) with supplemental potassium and spironolactone (Aldactone)
- Gentle positioning (osteoporosis)
- Sensitivity to muscle relaxants
- Continue exogenous supplemental steroids
- Adrenalectomy
- hydrocortisone succinate 100 mg Q8H
- prepare for blood loss from vascular tumor
- unintentional pleural penetration -> pneumothorax
- Primary adrenal insufficiency (Addison's disease)
- Destruction of adrenal gland
- Combined mineralocorticoid and glucocorticoid deficiency
- Signs
- hyponatremia
- hyperkalemia
- hypovolemia
- hypotension
- metabolic acidosis
- weakness
- fatigue
- hypoglycemia
- hypotension
- weight loss
- hyponatremia
- etomidate
- longterm administration (hours to days) suppresses adrenal function
- Secondary adrenal insufficiency
- Inadequate pituitary ACTH secretion
- Most commonly due to exogenous steroid administration
- Mineralocorticoid secretion usually adequate
- Acute adrenal insufficiency (addisonian crisis)
- During stress (infection, trauma, surgery) in steroid-dependent patients not treated with increased doses
- Signs
- circulatory collapse
- fever
- hypoglycemia
- depressed mentation
- Ensure adequate steroid replacement during perioperative period
- Patients after > 5 mg prednisone (or equivalent) daily for > 2 weeks any time in preoperative year
- Hydrocortisone phosphate 100 mg Q8H, starting preop
- Alternately: hydrocortisone 25 mg at induction, then 100 mg over next 24 hours
- Achieves cortisol levels at least as high as in normal patients during elective surgery
- May be especially appropriate for diabetics (better blood glucose control)
