Post-Operative Blood Pressure Management in Bilateral Adrenalectomy Patients

Causes of Hypotension

Removal of both adrenal glands results in acute adrenal insufficiency with inadequate cortisol and aldosterone production, leading to hypotension 1
Patients who experience intraoperative hypotension are more likely to develop recurrent hypotension in the postoperative period, suggesting an autonomic endotype that predisposes to hypotension 2
Inadequate fluid replacement during surgery can lead to hypovolemia 3
Only about 54% of patients with suspected hypovolemia actually respond to fluid boluses, suggesting that vascular tone or inotropy issues may be responsible in the remaining cases 3
Passive leg raise (PLR) test can help identify patients who will respond to fluid therapy (positive likelihood ratio = 11) 3

Postoperative hypertension is characterized by sympathetic stimulation resulting in catecholamine release, vasoconstriction, tachycardia, and impaired baroreceptor sensitivity 4
Hypertension often occurs with sympathetic nociceptive stimulation during induction of anesthesia, during surgery, and with acute pain in the early postoperative period 5
Excessive pain is associated with higher risk of developing postoperative hypertension 4
Hypothermia can trigger hypertension in the immediate postoperative period 5
Hypoxia can lead to sympathetic stimulation and hypertension 5, 3

The British Journal of Anaesthesia recommends performing bedside assessment to define the cause of hypotension 3
Consider PLR test to determine if inadequate preload is contributing to hypotension 3
If PLR test is positive, administer intravenous fluid; if negative, consider vasopressor or inotropic support 3
All patients with bilateral adrenalectomy require postoperative corticosteroid supplementation until recovery of the hypothalamus-pituitary-adrenal axis 1
Standard replacement includes hydrocortisone 15-25 mg daily in split doses and fludrocortisone 50-200 μg as a single daily dose 1
Determine if there is a reversible underlying cause of hypertension (pain, anxiety, hypoxemia, hypothermia, urinary retention) 3
Common non-pharmacological interventions include supplemental oxygen for hypoxemia, forced air warmer for hypothermia, catheterization for urinary retention, and verbal reassurance/anxiolytics for anxiety 3
Treatment goal should be based on preoperative blood pressure with a target of approximately 10% above baseline 3
Untreated postoperative hypertension increases the risk of myocardial ischemia, myocardial injury, infarction, arrhythmia, pulmonary edema, stroke, and surgical site bleeding 4

Greater frequency of postoperative blood pressure measurement helps identify risk of harm and clinical deterioration earlier 4
All patients with adrenal insufficiency should wear medical alert identification and carry a steroid alert card 1
Patients should be reviewed at least annually with assessment of health and well-being, weight, blood pressure, and serum electrolytes 1
Monitor for the development of new autoimmune disorders, particularly hypothyroidism 1

Assuming all hypotension is due to hypovolemia - approximately 46% of hypotensive patients do not respond to fluid boluses 3
Failing to recognize adrenal insufficiency as a cause of refractory hypotension 1
Delaying corticosteroid replacement in patients with bilateral adrenalectomy 1
Not addressing pain, anxiety, and other reversible causes before treating hypertension pharmacologically 4, 3