Post-Adrenalectomy Management

Immediate Post-Operative Care

The American Society of Anesthesiologists recommends administering hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24 hours until oral intake is established, for patients with cortisol-secreting tumors 1, 2
The Endocrine Society suggests doubling the usual replacement dose (typically 20-10-10 mg hydrocortisone) for 48 hours to one week, depending on surgical complexity, once stable and taking oral medications 3

The American College of Endocrinology recommends lifelong glucocorticoid and mineralocorticoid replacement for patients who have undergone bilateral adrenalectomy, with standard maintenance including hydrocortisone 15-25 mg daily and fludrocortisone 0.05-0.2 mg daily 1, 2, 3
Patients must be educated on "Sick Day Rules": double glucocorticoid doses during illness, injury, or physiological stress, as advised by the American Association of Clinical Endocrinologists 4, 3

The American Medical Association recommends that all patients on glucocorticoid replacement carry a steroid emergency card and wear medical alert identification, and provide hydrocortisone emergency self-injection kits (100 mg IM) for use during severe illness, vomiting, or inability to take oral medications 4, 3
The American Heart Association suggests educating patients and family members on recognizing adrenal crisis: severe weakness, persistent vomiting, hypotension, confusion, or collapse 4, 5

The Society of Critical Care Medicine recommends minor illness/stress: double usual oral dose until recovery, and major illness, surgery, or trauma: hydrocortisone 100 mg IV/IM immediately, followed by 200 mg/24 hours continuous infusion or 50 mg IV/IM every 6 hours 4, 3, 1, 2

The American Association of Clinical Endocrinologists recommends monitoring for signs of under-replacement: fatigue, orthostatic hypotension, hyponatremia, hyperkalemia, and signs of over-replacement: weight gain, hyperglycemia, hypertension, osteoporosis, for patients on glucocorticoid replacement 4, 5, 3
The National Kidney Foundation suggests annual clinical assessment of replacement adequacy and comorbidities, and annual potassium levels to detect rare contralateral disease in aldosteronoma patients 6

The American College of Physicians recommends never using dexamethasone alone for primary adrenal insufficiency as it lacks mineralocorticoid activity, and patients taking CYP3A4 inducers (rifampin, phenytoin, phenobarbital) may require higher hydrocortisone doses due to accelerated metabolism 2, 7, 5