Post-Operative Management of Adrenal Insufficiency After Adrenalectomy for Cushing Syndrome

Immediate Perioperative Management

The American College of Surgeons recommends stress-dose hydrocortisone at surgery and immediately postoperatively for patients with Cushing syndrome due to adrenal adenoma, as removal of the adenoma results in tertiary adrenal insufficiency 1, 2.
For pediatric patients, the Endocrine Society suggests hydrocortisone 2 mg/kg at induction, followed by continuous IV infusion based on weight (25-150 mg/24 hours depending on weight and pubertal status) 1.

The American Association of Clinical Endocrinologists recommends doubling the usual oral hydrocortisone doses for 48 hours, then reducing to normal replacement doses over up to a week 1.
The European Society of Endocrinology suggests continuing physiologic replacement doses (typically 15-25 mg hydrocortisone daily in divided doses) until HPA axis recovery is documented 1.
Serial morning cortisol monitoring is essential to guide steroid tapering and assess HPA axis recovery, as recommended by the American College of Endocrinology 1.

The Anaesthesia society recommends stress-dose coverage during intercurrent illness, trauma, or subsequent surgery until HPA axis recovery is confirmed 1, 3.
Patients should be educated on "sick day rules" (doubling steroid doses during illness) and carry emergency hydrocortisone, as suggested by the American College of Emergency Physicians 3.

Regular endocrine follow-up during the recovery phase should assess signs of adrenal insufficiency requiring dose adjustment, as recommended by the Endocrine Society 1.
Morning cortisol levels should be monitored to guide tapering and eventual discontinuation, as suggested by the American Association of Clinical Endocrinologists 1.