Total knee arthroplasty was subsequently performed under general anesthesia with desflurane as scheduled, with an uneventful intraoperative course. A 10-g dextrose intravenous infusion swiftly resolved the dizziness and a hypoglycemic attack was subsequently diagnosed. A low blood glucose level of 52 mg/dL was detected. At 2 pm on the day of surgery, the patient suffered from dizziness just before entering the operating room. The patient adhered nil per os after midnight before surgery. The results of preoperative blood tests were unremarkable ( Table 1). On physical examination, the patient’s body mass index was 20.6 kg/m 2 (height 146 cm, weight 44 kg), body temperature was 35.9☌, blood pressure was 105/63 mmHg, and heart rate was regular at 72 beats per min. She had no smoking history and only drank alcohol socially. The patient had not received any steroids either orally, by injection or topically. She was not on any medications, including over-the-counter medications, or supplements except for the levothyroxine. She had undergone three uncomplicated vaginal deliveries when she was 28, 32, and 35 years of age, and regularly menstruated until natural menopause when 52 years old. With the exception of levothyroxine supplementation and osteoarthrosis, the patient had an unremarkable medical record, with no history of diabetes mellitus, head injury, severe headache, stroke, tumor, or radiation therapy. She had taken 50 µg levothyroxine once daily for ten years, but the detailed indication for this was unknown. Because patients with adrenal insufficiency require appropriate perioperative corticosteroid supplementation, clinicians should give priority to identifying the underlying etiology of hypoglycemia over non-urgent elective surgery when these co-occur.Ī 65-year-old woman was admitted for elective total arthroplasty for osteoarthrosis of the right knee. Adrenal insufficiency is latent in patients with hypoglycemia episodes. After the administration of hydrocortisone as maintenance replacement therapy, the patient’s prolonged postoperative nausea disappeared. Finally, the patient was diagnosed as having empty sella syndrome with ACTH and GH deficiencies. While serum cortisol did not increase on a rapid ACTH stimulation test, urinary free cortisol excretion responded to a prolonged ACTH stimulation test. ACTH and growth hormone (GH) did not respond to testing with corticotropin-releasing hormone and GH–releasing peptide-2, respectively. An empty sella and bilateral adrenal atrophy were evident in imaging studies. The morning serum cortisol level was 0.15 µg/dL with undetectable adrenocorticotropic hormone (ACTH), and the insulin-like growth factor-1 level was 9 ng/mL. Although a hypoglycemic attack did not recur, further evaluation was required because of nausea that persisted after surgery. A dextrose infusion immediately corrected the hypoglycemia, and a total knee arthroplasty was then performed. On the day of surgery, the patient suffered from a hypoglycemic attack (52 mg/dL) after preoperative overnight fasting. There were no specific complaints except for knee flexion contractures, and the results of preoperative tests were unremarkable. A 65-year-old woman without a history of diabetes mellitus was admitted for elective total knee arthroplasty for osteoarthrosis.
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