ACUTE POSTOPERATIVE ADRENAL INSUFFICIENCY

Acute adrenal insufficiency is an uncommon complication of lung cancer and adrenal metastasis resection. Diagnosis is difficult to establish but an early recognition and treatment may be lifesaving. A 55-year-o ld man underwent right upper lobectomy and adrenalectomy for lung carc inoma with right adrenal metastasis. Anaesthesia was obtained with pro pofol, alfentanil, atracurium and isoflurane. Blood pressure remained stable throughout surgical procedure and blood loss was about 3 000 mi . Several hours after the end of the procedure which was uneventful th e circulator status worsened. The blood pressure was initially control led with 500 mi of gelatin. External blood loss was about 200 mi. Clin ical examination, chest X-ray and ECG were normal. Postoperative labor atory data showed a serum sodium at 134 mmol(-1) l(-1) and a serum pot assium 5.1 mmol l(-1); haemoglobin concentration was 93 g l(-1) Arteri al blood gas analysis, with a 51 min(-1) nasal o(2) flow showed a Pao( 2) at 108 mmHg, a Pao(2) at 30 mmHg and a pH at 7.44. Twelve hours lat er, a transient cardiac arrest occurred which responded to fluid load, dopamine and dobutamine. Six hours later, the patient went in ventric ular fibrillation respanding to an external electric countershock. No change in clinical status was noticed, except hyperthermia at 39.5 deg rees C. Serum potassium concentration before cardiac arrest was 4.7 mm ol l(-1). Main considered diagnoses were septic shock and acute adrena l insufficiency. Antibiotics (imipenem, amikacin and vancomycin) and h ormonal treatment (hydrocortisone 200 mg day(-1)), after blood samples had been obtained for bacteriological and hormonal examinations. The patient's condition improved dramatically within 48 hours. Shock was u nder control, dopamine and dobutamine were rapidly discontinued. Stimu lation of the adrenals with synthetic corticotrophin tetracosactide (S ynacthene(R) 250 mu g) demonstrated failure of the serum cortisol to r ise. The cortisol concentrations were very low before and after stimul ation (1.4 mu g 100 ml(-1) before stimulation and 0.1 mu g 100 ml(-1) thereafter). These data as well as negative bacteriological data subst antiate the diagnosis of acute adrenal insufficiency. A computer tomog raphy showed an enlargement and inhomogeneous mixed-density of the rem aining adrenal which was normal preoperatively. A CT-guided needle bio psy obtained necrotical and haemorrhagic tissue but no tumoral cells. It was concluded that adrenal insufficiency was due to necrosis of the remaining gland. Adrenal necrosis and haemorrhage has been described after sepsis, major trauma, chronic illness, severe surgical stress an d systemic anticoagulant therapy. It is a well known but uncommon comp lication of metastatic carcinoma. In this case, neither heparin was ad ministered nor sepsis occurred and it is speculated that this adrenal gland could have been metastatic with a special susceptibility to necr osis. Initialtime course was satisfying and the patient was discharged to medical unit ten days after surgery. However three days later, a v ascular cerebral haemorrhage resulted in death.