Insuffisance surrénalienne aiguë postopératoire

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 life-saving. A 55-year-old man underwent right upper lobectomy and adrenalectomy for lung carcinoma with right adrenal metastasis. Anaesthesia was obtained with propofol, alfentanil, atracurium and isoflurane. Blood pressure remained stable throughout surgical procedure and blood loss was about 3 000 ml. Several hours after the end of the procedure which was uneventful the circulator status worsened. The blood pressure was initially controlled with 500 ml of gelatin. External blood loss was about 200 ml. Clinical examination, chest X-ray and ECG were normal. Postoperative laboratory data showed a serum sodium at 134 mmol⁻¹ · l⁻¹ and a serum potassium 5.1 mmol · l⁻¹ ; haemoglobin concentration was 93 g · l⁻¹. Arterial blood gas analysis, with a 5 l · min⁻¹ nasal o₂ flow showed a Pao₂ at 108 mmHg, a Paco₂ at 30 mmHg and a pH at 7.44. Twelve hours later, a transient cardiac arrest occurred which responded to fluid load, dopamine and dobutamine. Six hours later, the patient went in ventricular fibrillation respanding to an external electric countershock. No change in clinical status was noticed, except hyperthermia at 39.5°C. Serum potassium concentration before cardiac arrest was 4.7 mmol · l⁻¹. Main considered diagnoses were septic shock and acute adrenal insufficiency. Antibiotics (imipenem, amikacin and vancomycin) and hormonal 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 under control, dopamine and dobutamine were rapidly discontinued. Stimulation of the adrenals with synthetic corticotrophin tetracosactide (Synacthene® 250 μg) demonstrated failure of the serum cortisol to rise. The cortisol concentrations were very low before and after stimulation (1.4 μg · 100 ml⁻¹ before stimulation and 0.1 μg · 100 ml⁻¹ thereafter). These data as well as negative bacteriological data substantiate the diagnosis of acute adrenal insufficiency. A computer tomography showed an enlargement and inhomogeneous mixed-density of the remaining adrenal which was normal preoperatively. A CT-guided needle biopsy 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 and systemic anticoagulant therapy. It is a well known but uncommon complication of metastatic carcinoma. In this case, neither heparin was administered nor sepsis occurred and it is speculated that this adrenal gland could have been metastatic with a special susceptibility to necrosis. Initialtime course was satisfying and the patient was discharged to medical unit ten days after surgery. However three days later, a vascular cerebral haemorrhage resulted in death.