Adrenal Insufficiency
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Adrenal Insufficiency

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Adrenal Insufficiency Presentation Transcript

  • 1. بسم الله الرحمن الرحيم
    RIBAT UNIVERSITY HOSPITAL
    DEPARTMENT OF MEDICINE
    Unite (E)
    Adrenal Insufficiency
    Dr. EyadGadour
    (MBBS National Ribat University)
  • 2. Basics Description
    - Inadequate hydrocortisone secretion to meet body's stress requirement
    - Adrenal deficiency:
    1- Inadequate cortisol
    2- Unresponsive to stimulation with adrenocorticotropic hormone (ACTH)
    - Functional hypoadrenalism:
    1- Inadequate cortisol
    2- Partial responsive to stimulation with ACTH
    - Addisonian crisis (acute adrenal insufficiency):
    1- Life-threatening emergency
    2- Precipitated by intensification of:
    * Chronic adrenal insufficiency
    * Acute adrenal hemorrhage
    * Rapid steroid withdrawal
    * Treatment of hypothyroidism with unrecognized adrenal disease
    * Steroid-dependent patient under stress owing to pregnancy, surgery, trauma, infection, or dehydration
  • 3. EtiologyPrimary Adrenal Failure
    1- Adrenal dysgenesis/impaired steroidogene:
    Congenital hypoplasia
    Allgrove syndrome:
    ACTH resistance
    Achalasia
    Alacrima
    Glycerol kinase deficiency:
    Psychomotor retardation
    Hypogonadism
    Muscular dystrophy
    Congenital hyperplasia
    Aldosteronesynthetase deficiency
    Mitochondrial disease
  • 4. 2- Adrenal destruction:
    - Autoimmune:
    1- Autoimmune polyglandular syndrome types 1 and 2 (alopecia universalis, chronic mucocutaneouscandidiasis, hypoparathyroid, thyroid autoimmunity, diabetes, celiac disease, pernicious anemia)
    2- Adrenoleukodystrophy
    - Infectious:
    1- Granulomatous: tuberculosis
    2- Protozoal and fungal: histoplasmosis, coccidioidomycosis, candidiasis
    3- Viral: cytomegalovirus, herpes simplex virus, and HIV
    4- Bacterial
    - Infiltration:
    1- Sarcoid
    2- Neoplasm
    3- Hemochromatosis
    4- Amyloidosis
    5- Iron depletion
  • 5. 3- Postadrenalectomy
    4- Hemorrhage:
    1- Sepsis: particularly meningococcemia, Pseudomonas infection
    2- Birth trauma/anoxia
    3- Pregnancy
    4- Seizures
    5- Anticoagulants
    6- Rhabdomyolysis
    5- Pharmacologic inhibition:
    Etomidate((Amidate), a nonbarbiturate, is used for induction of anesthesia).
    Herbal medications(الاعشاب)
    Ketoconazole ( gluoccorticoid antagonist )
    Metyrapone
    Suramin
  • 6. Secondary Adrenal Failure
    Pituitary insufficiency:
    - Sepsis
    - Head trauma
    - Hemorrhage
    - Infarction (Sheehan syndrome)
    - Infiltration: neoplasm, amyloid, sarcoid, hemochromatosis
    - Adrenocorticotropic hormone deficiency
    - Pharmacologic: glucocorticoid administration, herbal medications
    Tertiary Adrenal Failure
    - Hypothalamus insufficiency
    - Sepsis
    - Infiltrative: neoplasm, amyloid, sarcoid, hemochromatosis
    - Head trauma
  • 7. Diagnosis
    Signs and Symptoms
    Symptoms:
    Depression
    Lethargy
    Malaise
    Myalgias
    Anorexia
    Abdominal pain
    Nausea
    Vomiting
    Dehydration (found in primary adrenal insufficiency only)
    Salt craving
    Signs:
    Fever or hypothermia
    Mental status changes
    Tachycardia
    Orthostatic blood pressure changes or frank shock
    Weight loss
    Goiter
    Hypogonadism
    Hyperkalemia
    Sodium depletion
    Eosinophilia
    Hyperpigmentation (found in primary adrenal insufficiency only)
    Vitiligo
    Addisonian crisis:
    Hypotension and shock
    Hyponatremia
    Hyperkalemia
    Hypoglycemia
  • 8. Essential Workup
    Laboratory confirmation of diagnosis not possible in emergency department
    Adrenal crisis: life-threatening condition:
    High degree of suspicion should prompt initiation of therapy before definitive diagnosis.
    Plasma cortisollevel <20 آµg/dL accompanied by shock suggests adrenal insufficiency.
    Electrolytes:
    Potassium
    Sodium
    BUN, creatinine:
    Elevated owing to dehydration
    Serum glucose levels may be low
  • 9. Tests
    Lab
    CBC with differential:
    Anemia
    Eosinophilia
    Lymphocytosis
    Arterial blood gases:
    Hypoxemia
    Acidosis
    Cosyntropin stimulation test:
    Adrenal deficiency:
    Random serum cortisol <20 آµg/dL (while stressed)
    ACTH stimulation unresponsive
    Functional hypoadrenalism:
    Random serum cortisol = 20 آµg/dL (while stressed)
    Sixty minutes post ACTH stimulation <30 آµg/dL or delta cortisol (60 minutes - baseline) = 9 آµg/dL
    Search for underlying infection.
    Imaging
    ECG
    Chest radiograph
  • 10. Differential Diagnosis
    Sepsis
    Shock from any cause
    Acute abdominal emergency
  • 11. Treatment
    Initial Stabilization
    Airway, breathing, and circulation management (ABCs)
    Cardiac monitor
    Blood pressure support for hypotension:
    Normal saline (0.9%) IV fluids 500 mL–1 L (peds: 20 mL/kg) bolus
    Avoid pressors (if possible):
    May precipitate dysrhythmias
    Supplemental oxygen to meet metabolic needs
    Correct hyperthermia:
    Initiate cooling measures.
    ED Treatment
    Glucocorticoid replacement:
    Hydrocortisone: 100 mg or Dexamethasone: 4 mg
    Dexamethasone will not interfere with results of cosyntropin stimulation tests.
    Volume expansion:
    D5W 0.9% normal saline at rate of 500–1,000 mL/h for first 3–4 hours
    Care should be taken to note patient's age, volume, and cardiac and renal function.
    For hypoglycemia:
    D50W
    Treat life-threatening dysrhythmias secondary to hyperkalemia with calcium ,Sodium bicarbonate: 1–2 mEq/kg IV, and Insulin (regular): 10 units by IV push
    /glucose.
    Identification and correction of underlying precipitant
  • 12. Follow-Up Disposition
    Admission Criteria
    All patients with acute adrenal insufficiency
    ICU admission for patients with unstable or potentially unstable cases
    Discharge Criteria
    Normal laboratory evaluation with treated adrenal insufficiency
  • 13. Thank you