[Severe perioperative hypotension after nephrectomy with adrenalectomy].
A 70-year-old obese, hypertensive woman taking angiotensin converting enzyme (ACE) inhibitors and chlorthalidone but with no history of corticosteroid treatment or hypothalamus-hypophyseal-adrenal disease, underwent nephrectomy and adrenalectomy under combined general and epidural anesthesia. Severe hypotension with oliguria developed during surgery and persisted during postoperative recovery, with anuria, metabolic acidosis, hyponatremia and hyperpotassemia. Although the symptoms were initially attributed to prior treatment with ACE inhibitors and diuretics together with combined anesthesia, the patient's lack of response to crystalloid, colloid and inotropic catecholamine therapy in the context of anuria, metabolic acidosis, hyponatremia and hyperpotassemia led us to consider a diagnosis of Addisonian crisis. Blood samples were taken to determine adrenocorticotropic hormone levels, and hydrocortisone treatment was started. The patient responded to treatment and cortisol levels fell, confirming the diagnosis of adrenal insufficiency. Compensatory endrocrine secretion of cortisol by the contralateral adrenal gland has been observed in patients undergoing nephrectomy and adrenalectomy for excision of a hypernephroma, and replacement therapy is therefore not recommended. Perioperative Addisonian crises have also been described in patients suffering great surgical stress, and severe hypotension has been observed in patients on long-term treatment with ACE inhibitors after induction of general anesthesia and after epidural anesthesia with local anesthetics. The combination of these factors made rapid diagnosis and start of appropriate therapy difficult.
Cassinello Ogea
C
C
Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Miguel Servet, Zaragoza.
Girón Nombiela
J A
JA
Ruiz Tramazaygues
J
J
Izquierdo Villarroya
B
B
Sánchez Tirado
J A
JA
Almajano Domínguez
R M
RM
Oro Fraile
J
J
D000224:Addison Disease / Q000209:etiology* / Q000503:physiopathology; D000315:Adrenalectomy / Q000009:adverse effects*; D000324:Adrenocorticotropic Hormone / Q000097:blood; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D001002:Anuria / Q000209:etiology; D002752:Chlorthalidone / Q000009:adverse effects / Q000627:therapeutic use; D003937:Diagnosis, Differential; D004232:Diuretics / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism / Q000627:therapeutic use; D006973:Hypertension / Q000150:complications / Q000188:drug therapy; D007030:Hypothalamo-Hypophyseal System / Q000503:physiopathology; D017706:Lisinopril / Q000009:adverse effects / Q000627:therapeutic use; D009392:Nephrectomy; D009765:Obesity / Q000150:complications; D010913:Pituitary-Adrenal System / Q000503:physiopathology; D011704:Pyelonephritis / Q000601:surgery
D000806:Angiotensin-Converting Enzyme Inhibitors; D004232:Diuretics; D000324:Adrenocorticotropic Hormone; D017706:Lisinopril; D002752:Chlorthalidone; D006854:Hydrocortisone