Recommended
More Related Content
What's hot
What's hot (20)
Similar to Adrenal insufficiency crisis
Similar to Adrenal insufficiency crisis (20)
More from DrArpan Chouhan
More from DrArpan Chouhan (11)
Recently uploaded
Recently uploaded (20)
Adrenal insufficiency crisis
- 2. Adrenal Insufficiency ● Pathophysiology ● Primary failure (aka Addison’s disease) ● Deficiency of cortisol and aldosterone production
- 3. Adrenal Insufficiency ● Secondary failure ● Due to decreased production of ACTH ● Deficiency of only cortisol production ● Aldosterone is regulated by renin-angiotensin system
- 4. Adrenal Insufficiency ● Symptoms ● Chronic failure vague and nonspecific
- 6. Adrenal Insufficiency ● Acute symptoms ● Ranges from acute gastroenteritis with nausea, vomiting, fever and dehydration to vascular collapse or death ● Hypotension or shock out of proportion to severity of illness. ● Additional symptoms based on etiology: ● Abdominal pain for adrenal hemorrhage/infarction ● Headache suggesting acute pituitary apoplexy
- 7. Adrenal Insufficiency ● Differential Diagnosis ● Chronic ● Anorexia ● Carcinoma ● Chronic fatigue syndrome ● Polymyalgia rheumatica ● Myopathy ● Hypothyroidism ● Flu syndrome ● Acute ● Various causes of shock
- 8. Adrenal Insufficiency ● Diagnostic strategies ● Chronic ● AM cortisol measurement (normally 10 and 20 mcg/dL) ● If below 3 mcg/dL is diagnostic of hypoadrenalism ● If above 20 mcg/dL excludes diagnosis ● ACTH (cosyntropin) stimulation test confirmatory ● Obtain baseline cortisol ● Then administer 250mcg of ACTH ● Repeat levels at 30-60min ● Normal levels should exceed 20mcg/dL ● AM ACTH level ● High level confirms primary ● Low level confirms secondary
- 9. Adrenal Insufficiency ● Diagnosis (cont’d) ● Acute crisis ● Random cortisol ● <15 mcg/dL = diagnostic ● 15-33 mcg/dL = indeterminant ● >33 mcg/dL = excludes ● ACTH stimulation test ● Rise of< 9 mcg/dL diagnostic ● Hypoadrenalism of Sepsis and Critical Illness ● Random cortisol <25 mcg/dL = likely ● ACTH stimulation test <9 mcg/dL = diagnostic
- 10. Adrenal Insufficiency ● Management of acute insufficiency ● ABCs, 2 large bore IVs place ● Look for underlying cause ● Infuse 2-3 L of 0.9% NS ● Check for hypoglycemia ● Give Hydrocortisone 50-100mg q6-8 hrs ● Taper after 24 hours ● Dexamethasone (o.1 mg/kg) ● Advantage of not interfering with cortisol measurement
Editor's Notes
- In Western world most common cause is 2/2 autoimmune adrenalitis. In developing world, the most common cause is TB. While adrenal tumors can cause insufficiency, it is seen rarely since over 90% of adrenal have to be destroyed before function is affected. Etomidate also inhibits cortisol production, but almost all of it resolved by 48 hours. What is adrenal hemorrhage caused by meningococcemia called—Waterhouse-Friderichsen syndrome
- The most common cause is exogenous therapy—reduced function can be seen with supraphysiologic doses (hydrocortisone 30mg, prednisone 7.5mg or dex 0.75mg daily of glucocorticoid for >3 weeks but as little as 5 days if dose exceeds 20mg of prednisone.
- Patients with Addison’s disease will complain in addition to those symptoms salt craving, postural dizziness or syncope because of mineralocorticoid deficiency. With lack of aldosterone they lose sodium and do not excrete potassium in the kidneys. In addition this leads to increased antidiuretic hormone secretion that leads to hyponatermia. Because ACTH is high, there will be hyperpigmentation. In contrast, pts with secondary AI will not have salt craving and hyperkalemia because renin-aldosterone axis are intact. They also lack the hyperpigmentation since there is an absenece of ACTH. However, they may have deficiency of other pituitary hormones, especially FSH and LH resulting in loss of libido, infertility, amenorrhea, and TSH.
- Diagnosis starts with AM cortisol mgmt. If any measurement is below 20mcg/dL, then a ACTH stim test needs to be done. ACTH level then confirms primary or secondary. There are some cases where ACTH test shows normal results in partial secondary. In that case, ACTH measurement in setting of administering metapyrone or hypoglycemia will be performed by the endocrinologist.
- If in acute crisis, it is indeterminant administer hydrocortisone.