Adrenalectomy

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
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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 the mass functional and/or if it it 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.

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

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

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications