ABSTRACT
BACKGROUND: Adrenal crisis after surgical procedure is a rare but potentially catastrophic life-threatening event. Its manifestations, such as hypotension, tachycardia, hypoxia, and fever mimic the other more common postoperative complications. Clinical outcome is dependent upon early recognition of the condition and proper management with exogenous steroid administration. CASE PRESENTATION: We report a 75-year-old man who presented with shock immediately after surgery for a femoral fracture from lung cancer metastasis. Anemia and severe hyponatremia were detected. Despite adequate fluid resuscitation, nonspecific symptoms including hypotension, tachycardia, hypoxia, fever and confusion occurred. Emergent CT revealed enlarged bilateral adrenal glands. Under the diagnosis of adrenal crisis due to metastatic infiltration of adrenal glands, the patient was treated with appropriate steroid replacement resulting in rapid improvement and recovery. CONCLUSION: We describe a case of adrenal crisis caused by the lack of adrenal reserve based on metastatic involvement and surgical stress, the first published case of adrenal crisis after surgery for a pathologic fracture from lung cancer metastasis. Surgeons treating pathologic fractures should be aware of this complication and familiar with its appropriate therapy because of increasing opportunity to care patients with metastatic bone tumors due to recent advances in cancer treatment.
Subject(s)
Adrenal Insufficiency/diagnosis , Arthroplasty, Replacement, Hip/adverse effects , Bone Neoplasms/secondary , Femoral Neck Fractures/surgery , Fractures, Spontaneous/surgery , Acute Disease , Adrenal Cortex Hormones/therapeutic use , Adrenal Insufficiency/drug therapy , Adrenal Insufficiency/etiology , Aged , Arthroplasty, Replacement, Hip/methods , Bone Neoplasms/complications , Femoral Neck Fractures/diagnostic imaging , Follow-Up Studies , Fractures, Spontaneous/diagnostic imaging , Fractures, Spontaneous/etiology , Humans , Lung Neoplasms/pathology , Lung Neoplasms/surgery , Male , Postoperative Complications/diagnosis , Postoperative Complications/drug therapy , Rare Diseases , Risk Assessment , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
We report an experience of anesthetic management of the ex-utero intrapartum treatment (EXIT) procedure performed in a fetus with congenital high airway obstruction syndrome (CHAOS) due to laryngeal atresia at 30 weeks' gestation. Anesthesia of the mother was induced with rapid sequence, and maintained with 3.5% sevoflurane in 100% oxygen and fentanyl before delivery. Two minimum alveolar concentration (MAC) sevoflurane provided excellent uterine relaxation without maternal hypotension. After hysterotomy, a sterile pulse oxymeter was placed on the fetus hand for monitoring fetal SpO2 and pulse rate, and a Doppler ultrasound transducer was applied to monitor fetal heart rate. Fentanyl (5 microg x dl(-1)) and pancuronium (0.2 mg x dl(-1)) were injected into the fetal upper arm in addition to transplacental anesthetic agents. The fetal heart rate and SpO2 were stable throughout the fetal manipulations, but the rise in SpO2 after initiating ventilation via tracheostomy was very slow. The uterine tone improved soon after discontinuing sevoflurane and oxytocin infusion was started after delivery. Surfactant administration before first ventilation is recommended in preterm babies undergoing EXIT procedure, and capnometer may be useful to confirm the adequate ventilation before cutting the umbilical cord.
