Appropriate perioperative management of a cortisol producing adrenal adenoma
Diabetes and hypertension should be adequately treated prior to surgery. Patients with Cushing’s syndrome have an increased relative risk for thromboembolic complications; therefore, measures to prevent venous thromboembolism (VTE) should be implemented. Intraoperative replacement of glucocorticoids is controversial for patients with Cushing’s syndrome.
However, patients with Cushing’s syndrome have a suppressed hypothalamic–pituitary–adrenal (HPA) axis, leading to atrophy of the contralateral gland.
Therefore, after adrenalectomy for cortisol-producing adrenal adenomas, patients generally require glucocorticoid replacement to prevent adrenal insufficiency.
A cosyntropin stimulation test can be done on postoperative day 1 to determine the need for glucocorticoid replacement after adrenalectomy; basal serum cortisol and plasma adrenocorticotropin (ACTH) levels should be checked, and serum cortisol level should be evaluated 60 minutes after IV administration of cosyntropin 250 mcg.
Patients do not need glucocorticoid replacement if the basal serum cortisol level is > 5 mcg/dL, the stimulated cortisol level is > 18 mcg/dL, and there are no clinical symptoms of adrenal insufficiency.
However, patients will need glucocorticoid replacement if the basal cortisol is ≦ 5 mcg/dL, the stimulated cortisol is ≦ 18 mcg/dL, or there are clinical symptoms of adrenal insufficiency.
The time required for the HPA axis to recover after surgery ranges from 6 to 18 months. Cosyntropin stimulation studies can be done every 3 to 6 months to determine when the steroid therapy can be discontinued.