1280

Abstract

Introduction: Case Reports: Acute adrenal insufficiency is rare following radical unilateral nephrectomy and adrenalectomy when the contralateral adrenal gland is normal. There are few case reports in literature describing perioperative adrenal insufficiency following this procedure and only one other case report that describes acute intraoperative adrenal insufficiency based on a PubMed search. A woman with a renal cell carcinoma undergoing a unilateral radical nephrectomy and adrenalectomy is presented. Hypotension, hypovolemia, hyponatremia, hyperkalemia and metabolic acidosis progressively develop after mass removal despite aggressive fluid resuscitation, resolving after glucocorticoid administration. A 55 year old, 41 kg woman presents to urology with lower abdominal pain and hematuria. A CT scan of her abdomen and pelvis revealed a 18.6 x 10 x 9.6 cm hypervascular and centrally necrotic left renal mass without evidence of vascular spread. She was scheduled for a unilateral radical nephrectomy, adrenalectomy, and retroperitoneal lymph node dissection. She was pre-admitted one day prior to her scheduled surgery for vascular embolization of the mass. The splenic artery, left renal artery and numerous lumbar collaterals were embolized, with post procedural imaging showing 90% success of embolization of the arterial supply to the tumor. Her preoperative vital blood pressure was 126/56, heart rate 86, oxygen saturation 97% on room air, hemoglobin 11.2 g/dl. Her chemistries were significant for sodium 143 mmol/L, potassium 4.0 mmol/L, chloride 106 mmol/L, bicarbonate 22 mmol/L, BUN 13 mg/dL, creatinine 0.86 mg/dL. General anesthesia was induced with propofol, fentanyl, and rocuronium and maintained through an endotracheal tube with sevoflurane. A post-induction arterial line was also placed. Transesophageal echocardiography (TEE) was performed intraoperatively, initially showing trivial tricuspid regurgitation (TR) but normal systolic and diastolic function and without other valvular abnormalities. Her intraoperative course was significant for progressive hypotension after mass removal, nephrectomy and adrenalectomy. A phenylephrine and norepinephrine infusion were started. At this time, she had received Plasma-Lyte 148 solution 3L, albumin 5% 250 ml, as well as 1 unit of packed RBCs. Her sodium 130 mmol/L, potassium 5.2 mmol/L, ionized calcium 1.22 mmol/L, glucose 168 mg/dL, lactate 5.6 mmol/L, hematocrit 35%. Intraoperative TEE at this time showed a low normal left ventricular filling and ejection fraction with adequate chamber sizes, no interventricular bowing or other signs of pulmonary embolism. Despite increasing vasopressor and ionotropic agent requirements, her hypotension persisted. Hydrocortisone 100 mg was given one hour prior to procedure end. The vasopressors infusions were rapidly titrated down to maintain a MAP of 60. The decision was made to leave her intubated and transfer to the intensive care unit given her persistent hypotension requiring low dosage of vasopressors. She received hydrocortisone 100 mg every 8 hours for two more doses followed by a one day taper. The norepinephrine infusion was rapidly weaned off in the ICU 8 hours after receiving her intraoperative dose and extubated on postoperative day 1. Laboratory studies on postoperative day 1 showed normalization of sodium 141 and potassium of 4.4. She was discharged to home after postoperative day 3.