Difference between revisions of "Adrenalectomy"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = ETT | ||
| lines_access = | | lines_access = 2 PIVs, +/- Arterial line | ||
| monitors = | | monitors = standard | ||
| considerations_preoperative = | | considerations_preoperative = Electrolytes | ||
| considerations_intraoperative = | | considerations_intraoperative = Rapid hemodynamic changes | ||
| considerations_postoperative = | | considerations_postoperative = Tumor withdrawal requiring steroid replacement | ||
}} | }} | ||
| Line 14: | Line 14: | ||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | === Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | ||
Key in the preoperative workup is determining if the mass is functional and/or if it is malignant. Functional tumors could produce cushings syndrome, hyper aldosteronism, or a pheochromocytoma | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
| Line 20: | Line 21: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Investigate headaches, fatigue, syncope | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |HTN, cardiac remodeling, HLD, | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| Line 35: | Line 36: | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Hypernatremia, hypokalemia | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| Line 41: | Line 42: | ||
|- | |- | ||
|Other | |Other | ||
| | |Obesity/cushingoid | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* Electrocardiogram to investigate potential arrhythmias or signs of electrolyte changes | |||
* Consider ECHO if clinical suspicion of cardiac remodeling/heart failure, long standing HTN, functional changes | |||
* CBC | |||
* CMP especially important for electrolyte evaluation | |||
* (typically preformed preop in adrenal mass workup) dexamethasone suppression test | |||
* Plasma metanephrines (Normetanephrine, Norepinephrine, Epinephrine , Dopamine) if concern for pheo | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
If the mass is small and nonfunctional, the surgical procedure can be straight foreword with minimal disruptions expected to the endocrine system. However if the mass is functional, tumor manipulation can precipitate large changes in glucose, electrolytes (potassium/sodium), blood pressure and HR. | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
Consider TAP block or epidural depending on extent of resection | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
2 peripheral IVs | |||
Arterial line for monitoring rapid hemodynamic changes and possibly frequent blood draws if functional tumor. If nonfunctional, typically no arterial line required | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
Standard | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
Lateral with surgical side up | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
PACU, typically, however can require ICU depending on extent of resection and changes in endocrine system | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
PCA for IV opiate therapy | |||
Consider regional such as TAP block vs Epidural if larger resection expected | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
Latest revision as of 02:46, 26 April 2023
Adrenalectomy
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
2 PIVs, +/- Arterial line |
| Monitors |
standard |
| Primary anesthetic considerations | |
| Preoperative |
Electrolytes |
| Intraoperative |
Rapid hemodynamic changes |
| Postoperative |
Tumor withdrawal requiring steroid replacement |
| Article quality | |
| Editor rating | |
| User likes | 0 |
An adrenalectomy is a surgical procedure to remove one or both adrenal glands, and is typically performed to remove a hormone-secreting tumor. The anesthetic approach to this procedure varies depending on the hormones produced by the tumor. If the tumor is a pheochromocytoma, unique considerations for preoperative optimization and perioperative management are required (see excision of pheochromocytoma).
Preoperative management
Patient evaluation
Key in the preoperative workup is determining if the mass is functional and/or if it is malignant. Functional tumors could produce cushings syndrome, hyper aldosteronism, or a pheochromocytoma
| System | Considerations |
|---|---|
| Neurologic | Investigate headaches, fatigue, syncope |
| Cardiovascular | HTN, cardiac remodeling, HLD, |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | |
| Renal | Hypernatremia, hypokalemia |
| Endocrine | |
| Other | Obesity/cushingoid |
Labs and studies
- Electrocardiogram to investigate potential arrhythmias or signs of electrolyte changes
- Consider ECHO if clinical suspicion of cardiac remodeling/heart failure, long standing HTN, functional changes
- CBC
- CMP especially important for electrolyte evaluation
- (typically preformed preop in adrenal mass workup) dexamethasone suppression test
- Plasma metanephrines (Normetanephrine, Norepinephrine, Epinephrine , Dopamine) if concern for pheo
Operating room setup
If the mass is small and nonfunctional, the surgical procedure can be straight foreword with minimal disruptions expected to the endocrine system. However if the mass is functional, tumor manipulation can precipitate large changes in glucose, electrolytes (potassium/sodium), blood pressure and HR.
Patient preparation and premedication
Regional and neuraxial techniques
Consider TAP block or epidural depending on extent of resection
Intraoperative management
Monitoring and access
2 peripheral IVs
Arterial line for monitoring rapid hemodynamic changes and possibly frequent blood draws if functional tumor. If nonfunctional, typically no arterial line required
Induction and airway management
Standard
Positioning
Lateral with surgical side up
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
PACU, typically, however can require ICU depending on extent of resection and changes in endocrine system
Pain management
PCA for IV opiate therapy
Consider regional such as TAP block vs Epidural if larger resection expected
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
Top contributors: Chris Rishel, Mitchel DeVita and tyler murphy