Adrenal insufficiency in patients with ruptured abdominal aortic aneurysms

Failure of the adrenocortical system after open repair of ruptured abdominal aortic aneurysm (RAAA) has never been reported, to our knowledge. This study was undertaken to examine the incidence and response to treatment of adrenal insufficiency in the RAAA population.

A 6-year retrospective analysis was carried out on data for all patients admitted after RAAA repair. A cosyntropin stimulation test (CST) was performed in patients with unexplained postoperative hypotension. Patients with adrenal insufficiency were given stress dose hydrocortisone, followed by slow hydrocortisone taper.

Twenty of 26 patients admitted after RAAA repair survived longer than 1 week. Nine of these 20 patients underwent CST because of unexplained hypotension, and six patients were found to have adrenal insufficiency. Compared with the three patients with normal CST and the 11 patients with normotension who did not require testing, patients with adrenal insufficiency had greater preoperative hypotension (83% vs 29%; P =.05), greater operative blood loss (7.0 +/- 1.6 L vs 3.0 +/- 0.9 L; P =.003), longer lower extremity ischemia time (5.0 +/- 2.3 hours vs 1.3 +/- 0.5 hours; P =.025), and lower intraoperative urine output (0.8 +/- 0.4 mL/kg/hr vs 2.1 +/- 0.6 mL/kg/hr; P =.023). No difference in length of stay (40 +/- 18 days vs 35 +/- 26 days), major complications (27% vs 32%), or overall mortality (17% vs 15%) was demonstrated with steroid therapy. Initiation of steroid therapy enabled weaning of vasopressor support within 48 hours in patients with adrenal insufficiency.

Adrenal insufficiency was identified in 67% of patients with RAAA with unexplained postoperative hypotension given a CST. Predictors of adrenal insufficiency after RAAA repair include preoperative hypotension and a complicated operative course. Steroid therapy can limit vasopressor dependence, and is not associated with increased morbidity or mortality.