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.

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