Post-Operative Management After Adrenalectomy for Adrenal Adenoma in Pediatric Cushing Syndrome

Immediate Perioperative Steroid Coverage

Major surgery in children requires hydrocortisone 2 mg/kg at induction followed by continuous IV infusion based on weight, with dosages of 25 mg/24 hours for patients up to 10 kg, 50 mg/24 hours for patients 11-20 kg, 100 mg/24 hours for prepubertal patients over 20 kg, and 150 mg/24 hours for pubertal patients over 20 kg, according to the Anaesthesia guideline society 1

The American Society of Anesthesiologists recommends stress-dose coverage is critical because the contralateral adrenal gland has been chronically suppressed by the autonomous cortisol production from the adenoma and cannot mount an adequate stress response immediately after surgery, with a strength of evidence based on expert opinion 1
Once stable, the child should receive double the usual oral hydrocortisone doses for 48 hours, then reduce to normal replacement doses over up to a week, as recommended by the Anaesthesia guideline society 1
Removal of a cortisol-secreting adrenal adenoma results in tertiary adrenal insufficiency because the hypothalamic-pituitary-adrenal (HPA) axis has been suppressed by chronic hypercortisolism, which is temporary and reversible in adrenal Cushing syndrome, according to the Endocrine Society 2

Serial cortisol monitoring is essential to guide steroid tapering and assess HPA axis recovery, with morning cortisol levels measured regularly during follow-up, as recommended by the Nature Reviews Endocrinology guideline society 3

Do not discontinue steroids too rapidly, as abrupt withdrawal can precipitate adrenal crisis, and the taper must be gradual and guided by biochemical monitoring, according to the Anaesthesia guideline society 1
Do not forget stress-dose coverage during intercurrent illness, until HPA axis recovery is confirmed, the child remains at risk for adrenal insufficiency during physiologic stress and requires stress-dose glucocorticoid coverage, as recommended by the Anaesthesia guideline society 1

Lifelong surveillance is NOT required for adrenal adenoma, unlike Cushing disease where recurrence can occur up to 15 years later, according to the Nature Reviews Endocrinology guideline society 4
Regular endocrine follow-up is needed during the recovery phase to monitor for signs of adrenal insufficiency, assess growth velocity and bone density recovery, guide steroid dose adjustments and eventual discontinuation, and confirm HPA axis recovery before stopping replacement therapy, as recommended by the Endocrine Society 2