J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Review

Volume 7, Number 1, January 2015, pages 1-7

Anesthetic Considerations on Adrenal Gland Surgery

**Table 1.** Conn’s Syndrome and Anesthetic Management
Conn’s syndrome	Treatment
Preoperative period
Preoperative hypokalemia	Begin spironolactone, supplement kalium
Hypertension	Continue preoperative antihypertensive drugs
Premedication	Adequate sedation
Intraoperative period
Metabolic alkalosis	Avoid hyperventilation
Hemodynamic state	Strict hemodynamic control
Potassium level, gas analysis	Frequent measures of acid-base status and potassium blood level

Table 1. Conn’s Syndrome and Anesthetic Management

Conn’s syndrome

Treatment

Preoperative period

Preoperative hypokalemia

Begin spironolactone, supplement kalium

Hypertension

Continue preoperative antihypertensive drugs

Premedication

Adequate sedation

Intraoperative period

Metabolic alkalosis

Avoid hyperventilation

Hemodynamic state

Strict hemodynamic control

Potassium level, gas analysis

Frequent measures of acid-base status and potassium blood level

**Table 2.** Clinical Manifestation of Cushing’s Syndrome [14]
Central obesity	Thin extremities
Supraclavicular fat	Proximal muscle weakness
Moon face	Hypertension
Buffalo hump	Hyperglycemia
Abdominal striae	Metabolic alkalosis
Skin thinning	Hypokalemia
Easy bruising	Menstrual irregularities
Osteopenia	Poor wound healing

Table 2. Clinical Manifestation of Cushing’s Syndrome [14]

Central obesity

Thin extremities

Supraclavicular fat

Proximal muscle weakness

Moon face

Hypertension

Buffalo hump

Hyperglycemia

Abdominal striae

Metabolic alkalosis

Skin thinning

Hypokalemia

Easy bruising

Menstrual irregularities

Osteopenia

Poor wound healing

**Table 3.** Perioperative Problems of Cushing’s syndrome Anesthetic Management
Cushing’s syndrome	Treatment
Preoperative period
Cortisol inhibition	Adrenal enzyme inhibitors
Hypertension	Continue chronic therapy except ACEI and ARB
Hyperglycemia	Stop oral therapy and begin insulin regimen
Hypokalemia	Begin spironolactone and supplement potassium
Perioperative hypercoagulative state	LMWH, lower-extremity compression devices, and early postoperative mobilization
Intraoperative period
Detailed anesthetic plan	General endotracheal anesthesia ± epidural
Positioning and taping	Careful and gentle positioning, avoid fractures
Premedication technique	Avoid deep sedation
Gastric aspiration risk	Drugs, rapid induction, Sellick maneuver
Airway management	Careful preoxygenation, ensure correct intubation
Venous access	Large bore peripherial and central venous catheters
Invasive monitoring	Radial artery cannulation, Swan-Ganz if required
Biochemistry tests	Close monitoring of glycemia, electrolytes, and pH
Postextubation respiratory failure	Awake extubation, close monitoring
Postoperative period
Acute pain therapy	Aggressive treatment, systemic/epidural opioid
Biochemistry tests	Close monitoring of glycemia, electrolytes, cortisol and pH
Postoperative respiratory failure	Respiratory exercises, pain killers, mobilization
Venous thrombotic episodes	LMWH, early mobilization

Table 3. Perioperative Problems of Cushing’s syndrome Anesthetic Management

Cushing’s syndrome

Treatment

Preoperative period

Cortisol inhibition

Adrenal enzyme inhibitors

Hypertension

Continue chronic therapy except ACEI and ARB

Hyperglycemia

Stop oral therapy and begin insulin regimen

Hypokalemia

Begin spironolactone and supplement potassium

Perioperative hypercoagulative state

LMWH, lower-extremity compression devices, and early postoperative mobilization

Intraoperative period

Detailed anesthetic plan

General endotracheal anesthesia ± epidural

Positioning and taping

Careful and gentle positioning, avoid fractures

Premedication technique

Avoid deep sedation

Gastric aspiration risk

Drugs, rapid induction, Sellick maneuver

Airway management

Careful preoxygenation, ensure correct intubation

Venous access

Large bore peripherial and central venous catheters

Invasive monitoring

Radial artery cannulation, Swan-Ganz if required

Biochemistry tests

Close monitoring of glycemia, electrolytes, and pH

Postextubation respiratory failure

Awake extubation, close monitoring

Postoperative period

Acute pain therapy

Aggressive treatment, systemic/epidural opioid

Biochemistry tests

Close monitoring of glycemia, electrolytes, cortisol and pH

Postoperative respiratory failure

Respiratory exercises, pain killers, mobilization

Venous thrombotic episodes

LMWH, early mobilization

**Table 4.** Sensitivity and Specificity of Pheochromocytoma Diagnosing Tests [10, 41]
Test/symptom	Sensitivity (%)	Specificity (%)
Vanillylmandelic acid	81	97
Catecholamine excretion	82	95
Metanephrine excretion	83	95
Abdominal CT scan	92	80
Paroxysmal hypertension, headache, sweating, tachycardia	90	95

Table 4. Sensitivity and Specificity of Pheochromocytoma Diagnosing Tests [10, 41]

Test/symptom

Sensitivity (%)

Specificity (%)

Vanillylmandelic acid

Catecholamine excretion

Metanephrine excretion

Abdominal CT scan

Paroxysmal hypertension, headache, sweating, tachycardia

**Table 5.** The Differences Between Phenoxybenzamine and Doxazosin
Phenoxybenzamine	Doxazosin
Non selective α1-adrenergic blocker	Selective α1-adrenergic blocker
Central signs present	No central signs (headache, nasal stuffiness)
β-blocker always necessary	β-blocker not always necessary
Prolonged and severe hypotension after adrenalectomy	No significant hypotension after adrenalectomy
Postural hypotension	No postural hypotension
Residual adrenergic blockade	No residual adrenergic blockade

Table 5. The Differences Between Phenoxybenzamine and Doxazosin

Phenoxybenzamine

Doxazosin

Non selective α1-adrenergic blocker

Selective α1-adrenergic blocker

Central signs present

No central signs (headache, nasal stuffiness)

β-blocker always necessary

β-blocker not always necessary

Prolonged and severe hypotension after adrenalectomy

No significant hypotension after adrenalectomy

Postural hypotension

No postural hypotension

Residual adrenergic blockade

No residual adrenergic blockade

**Table 6.** Vasoactive Drugs Used During Pheochromocytoma’s Resection
Drug’s name	Dose	Comments
Vasodilator drugs (hypotensives)
Propofol	2 - 2.5 mg/kg load, 25 - 75 μg/kg/min maintain	Local irritation, propofol infusion syndrome
Remifentanil	1 μg/kg load, 0.05 μg/kg/min maintain	Respiratory depression, hyperalgesia, vomiting
Dexmetedomidine	1 mg/kg load, 0.7 mg/kg/h maintain	Sedative effects
Nitroprusside	1 - 2 μg/kg/min	Severe hypotension, cyanide toxicity
Nitroglycerine	25 - 250 μg/min	Reflex tachycardia, methemoglobinemia
Nicardipine	5 mg/h	Braycardia, severe hypotension, cardiac blocks
Esmolol	5 - 10 mg/3 - 5 min bolus	AV block, bronchial hyperactivity
Labetalol	5 - 10 mg bolus
Urapidil	10 - 15 mg/h	Severe hypotension
Clonidine	0.1 - 1.2 mg	Rebound hypertension, dry mouth
Magnesium sulfate	1 - 8 mg load, 1 - 4 mg/h maintain	Potentiates muscle relaxants
Vasoconstrictor drugs (hypertensives)
Epinephrine	1 - 20 μg/min	Tachycardia
Norepinephrine	1 - 30 μg/min	Reflective bradycardia
Dopamine	5 - 10 μg/min	Tachycardia, arrhythmias
Phenilephrine	10 - 100 μg/min	Reflective bradycardia
Vasopressin	0.1 - 0.4 units/min	Myocardial infarction
Ephedrine	5 - 10 mg	None

Table 6. Vasoactive Drugs Used During Pheochromocytoma’s Resection

Drug’s name

Dose

Comments

Vasodilator drugs (hypotensives)

Propofol

2 - 2.5 mg/kg load, 25 - 75 μg/kg/min maintain

Local irritation, propofol infusion syndrome

Remifentanil

1 μg/kg load, 0.05 μg/kg/min maintain

Respiratory depression, hyperalgesia, vomiting

Dexmetedomidine

1 mg/kg load, 0.7 mg/kg/h maintain

Sedative effects

Nitroprusside

1 - 2 μg/kg/min

Severe hypotension, cyanide toxicity

Nitroglycerine

25 - 250 μg/min

Reflex tachycardia, methemoglobinemia

Nicardipine

5 mg/h

Braycardia, severe hypotension, cardiac blocks

Esmolol

5 - 10 mg/3 - 5 min bolus

AV block, bronchial hyperactivity

Labetalol

5 - 10 mg bolus

Urapidil

10 - 15 mg/h

Severe hypotension

Clonidine

0.1 - 1.2 mg

Rebound hypertension, dry mouth

Magnesium sulfate

1 - 8 mg load, 1 - 4 mg/h maintain

Potentiates muscle relaxants

Vasoconstrictor drugs (hypertensives)

Epinephrine

1 - 20 μg/min

Tachycardia

Norepinephrine

1 - 30 μg/min

Reflective bradycardia

Dopamine

5 - 10 μg/min

Tachycardia, arrhythmias

Phenilephrine

10 - 100 μg/min

Reflective bradycardia

Vasopressin

0.1 - 0.4 units/min

Myocardial infarction

Ephedrine

5 - 10 mg

None