Adrenocortical Insufficiency During Surgical Anesthesia

Abstract

Considerable interest in adrenocortical function during and following surgical intervention has been aroused in recent years. Two types of deficiency should be considered in relation to the generally accepted concept that stress caused by surgical trauma results in pituitary-adrenocortical stimulation : one is adrenal insufficiency due to excessive surgical trauma ; the second is the development of adrenocortical insufficiency following even relatively mild surgical trauma because of impaired adrenal function in patients previously treated with cortisone or similar adrenocortical steroids.The adrenal cortices of a patient become deficient after treatment for more than 2 weeks with adrenal steroids. If therapy is withdrawn abruptly the patient reacts as would a subject with Addison's disease. If corticosteroid therapy, usually taken orally, is discontinued the night before an operation, the superimposed surgical trauma may precipitate an acute adrenal insufficiency, manifested by metabolic imbalance and arterial hypotension.l-* Anesthesia per se may not actually aggravate such conditions. However, the anesthesiologist, as well as other members of the surgical team, is confronted with certain relevant problems that bear upon the diagnosis and treatment of adrenocortical insufficiency during surgery or immediately thereafter.Arterial hypotension is one of the signs of acute adrenal insufficiency, but it is usually a late manifestation. During surgical intervention, it is important to distinguish this type of hypotension from the reflex hypotension incident to mechanical stimulation of autonomic areas possessing vagal cardiac effector pathways, or from hypotension due to hypovolemia as a result of hemorrhage.In this presentation, the following points will be considered: (1) basic concepts of adrenocortical function ; (2) the modifying role of anesthesia ;( 3 ) behavior during relatively minor surgical operations of patients with adrenocortical insufficiency who are not receiving adrenocortical steroid therapy ; (4) behavior during major surgical interventions of patients with adrenocortical insufficiency supported by adequate hormonal therapy ; ( 5 behavior of patients during major surgery resulting in adrenocortical insufficiency.