Anesthetic Management for Rhinoplasty in a Patient with a History of Bilateral Adrenalectomy Due to Controlled Cushing’s Syndrome: A Case Report

Fatemeh  Eftekharian; Navid  Kalani; Arnoosh  Ghodsian; Reza  Sahraei

doi:10.18502/aacc.v12i4.21806

Fatemeh Eftekharian Department of Internal Medicine, Faculty of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran.
Navid Kalani Department of Anesthesiology, Faculty of Medicine, Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran.
Arnoosh Ghodsian Student Research Committee, Faculty of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran.
Reza Sahraei Department of Anesthesiology, Critical Care and Pain Management Research Center, Faculty of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran.

DOI: https://doi.org/10.18502/aacc.v12i4.21806

Keywords: Cushing’s syndrome; Bilateral adrenalectomy; Adrenal insufficiency; Perioperative steroid management; Anesthetic considerations; Rhinoplasty

Abstract

Bilateral adrenalectomy, in the event of elective surgery, poses problems for an anesthetic manager due to hemodynamic instability, glucocorticoid replacement dependency, adrenal insufficiency, or a whole series of their associated endocrine disorders, one of which is hypothyroidism. This case report deals primarily with the perioperative considerations and management of the patient with Cushing's syndrome, who was planned for elective rhinoplasty following bilateral adrenalectomy. A 33-year-old woman who underwent bilateral adrenalectomy in childhood due to Cushing's syndrome came for elective rhinoplasty to correct post-traumatic nasal septal deviation. The preoperative workup revealed severe hair loss, dry skin, symptoms of orthostatic hypotension, and a systolic blood pressure reading consistently below 80 mmHg. Laboratory investigations gave evidence of elevated TSH (18.9 mIU/L), suggestive of hypothyroidism. Therefore, she was referred to an endocrinologist, and treatment with levothyroxine and fludrocortisone was initiated. An improvement in thyroid function was established a month later (TSH: 1.9 mIU/L), and hypotension was controlled. Surgery was scheduled after getting approval from the anesthesiology team and a detailed risk discussion with an informed patient consenting to proceed. During surgery, constant monitoring of the patient's vitals was carried out. Everything went on very well, and the patient was discharged, stable. Among challenging patients such as those with adrenal insufficiency, careful preoperative evaluation, hormone imbalance correction, and proper steroid supplementation play a vital role in avoiding adrenal crisis states during or after surgery. Effective teamwork is achieved between anesthesiologists, endocrinologists, and surgeons in endeavoring to make a surgical outcome safe and successful.