Acute adrenocortical insufficiency / dental implant courses

Acute Adrenocortical
Insufficiency
(Adrenal Crisis; Addisonian crisis)
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Introduction
Acute adrenal insufficiency is a
Life-threatening emergency
caused by insufficient cortisol

Adrenal cortex
 Zona Glomerulosa
 Zona Fasciculata
 Zona Reticularis
 Mineralocorticoids
 Glucocorticoids
 Sex steroids

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

Stress

Situation that upsets homeostasis and
threatens one’s physical or emotional well-
being

Physical stressors
− injury, surgery, hemorrhage,
infection,intense exercise, temperature
extremes, pain, and malnutrition

Emotional stressors
− anger, grief, depression,anxiety, and
guilt

Stress response or general
Adaptation Syndrome (GAS)

elevated levels of epinephrine and
glucocorticoids,especially cortisol

Alarm reaction

Stage of resistance

Stage of exhaustion

The Alarm Reaction

Norepinephrine - sympathetic nervous
system

Epinephrine - Adrenal medulla

Fighting or escaping danger

Uses stored glycogen

Angiotensin raise the blood pressure

Aldosterone promotes sodium and water
conservation

The Stage of Resistance

Glycogen reserves exhausted

Alternative fuels for metabolism

This stage is dominated by cortisol

Cortisol - breakdown of fat and protein into
glycerol, fatty acids, and amino acids –
gluconeogenesis

Glucose-sparing effect

Inhibits protein synthesis

Long Term Effects???www.indiandentalacademy.com

HPA Axis

Hypothalamus

Corticotropin
Releasing
Hormone (CRH)

Pituitary

Adreno
Corticotropic
Hormone (ACTH)

Adrenal cortex

Cortisol and other
glucocorticoids

The Stage of Exhaustion

Fat depleted

Protein breakdown – energy

Hypertension

Hypokalemia

Alkalosis

resulting in nervous and muscular system
dysfunctions

Death frequently results from heart failure,
kidney failure, or overwhelming infectionwww.indiandentalacademy.com

Primary Vs Secondary
insufficiency
Hyperpigmentation
Dehydration
Hypotension
Hyperkalemia
Hyponatremia
Hypoglycemia
Not Present
Not Present
Less Prominent
Not Present
May Be Present
More Common

Factors • Stress (trauma, surgery, infection, or
prolonged fasting) in a patient with latent
insufficiency
• Sudden withdrawal of adrenocortical
hormone in a patient with chronic
insufficiency or in a patient with
temporary insufficiency due to
suppression by exogenous corticosteroids
• Bilateral adrenalectomy or removal of a
functioning adrenal tumor that had
suppressed the other adrenal
• Sudden destruction of the pituitary gland
(pituitary necrosis), or when thyroid
hormone is given to a patient with
hypoadrenalism
•

INDICATIONS OF GLUCOCORTICOSTEROID
USE

ALLERGIC DISEASES

EYE DISEASES

GASTROINTESTINAL DISEASES

HAEMATOPOIETIC DISORDERS

INFECTIONS

PULMONARY DISEASES

SKIN DISEASES

RULE OF TWO :
ADRENAL SUPPRESSION SUSPECTED ,

Dose of 20 mg or more

Via oral or parenteral route for a continuous period of 2
weeks

Within 2 years of dental therapy

PATHOPHYSIOLOGY

NORMAL ADRENAL FUNCTION

EXOGENOUS STEROID USE

WITHDRAWAL OF STEROID

Symptoms
• Headache
• Lassitude
• Nausea
• Vomiting
• Abdominal pain
• Diarrhea

Signs • Confusion or coma
• Fever ≥ 40.6 °C
• Collapse
• Bradycardia
• Hypotension
• Recurrent hypoglycemia and reduced
insulin requirements in patients with
preexisting type 1 diabetes mellitus
• Vomitting
• Cyanosis, dehydration, skin
hyperpigmentation, and sparse axillary
hair (if hypogonadism is also present)

LaboratoryFindings • ↑ Eosinophil count
• Hyponatremia or hyperkalemia (or
both)
• Hypoglycemia
• Hypercalcemia
• Blood, sputum, or urine culture may
be positive if bacterial infection is the
precipitating cause of the crisis

DIAGNOSIS
INSULIN TOLERANCE TEST
-GOLD STANDARD,TESTS HPA
AXIS
PROLONGED ACTH STIMULATION
TEST
CORTICOTROPIN RELEASING
HARMONE STIMULATION TEST
BASELINE CORTISOL LEVELS

Diagnosis • Simplified cosyntropin stimulation test
− Parenteral Synthetic ACTH1–24
(cosyntropin), 0.25 mg
− Serum is obtained for cortisol (30 to 60
minutes later)
− Normally, serum cortisol rises to at least 20
mcg/dL
− [For patients receiving corticosteroid
treatment, hydrocortisone must not be given
for at least 8 hours before the test. Other
corticosteroids (eg, prednisone,
dexamethasone) do not interfere with
specific assays for cortisol]
• Plasma ACTH is markedly elevated if the
patient has primary adrenal disease (generally >
200 pg/mL)www.indiandentalacademy.com

DifferentialDiagnosis
• Other causes of shock
− septic, hemorrhagic, cardiogenic
• Hyperkalemia {gastrointestinal bleeding,
rhabdomyolysis, hyperkalemic paralysis, and
certain drugs (eg, ACE inhibitors,
spironolactone)}

DifferentialDiagnosis • Acute adrenal insufficiency must be
distinguished from an acute abdomen in
which neutrophilia is the rule, whereas
adrenal insufficiency is characterized by a
relative lymphocytosis and eosinophilia
• Hyponatremia (hypothyroidism, diuretic
use, heart failure, cirrhosis, vomiting,
diarrhea, severe illness, or major surgery)
• Acute adrenal insufficiency must be
distinguished from an acute abdomen in
which neutrophilia is the rule, whereas
adrenal insufficiency is characterized by a
relative lymphocytosis and eosinophilia

PREVENTION
 Good history.
Awareness of the condition treated with
steroids.
Mild stress – Double daily dose.
Moderate stress – 100 mg
hydrocortisone.
Severe stress – 200 mg hydrocortisone.www.indiandentalacademy.com

ASOS RECOMMENDATION

Previously on cortisole for 6 months but presently
off – No supplementation.

Received steroids for more than 1 year but off for 1
year – No supplementation.

Recent course for 1 week – 200 mg Orally day
before surgery, 100 mg Orally postoperatively, 100
mg day after surgery.

Management
• Lay the patient flat with legs raised
• I.V. Hydrocortisone 200mg
• Summon medical assistance
• Take Blood for glucose and electrolyte
estimation
• Glucose (25g oral or i.v.) if hypoglycemic

Management
• I.V. infusion of normal saline or glucose-saline
− 1 litre (2 hour) with 200mg hydrocortisone sodium succinate
[repeat 4-6 hourly intervals]
• Monitor Blood Pressure
• Correct hyperthermia
− Initiate cooling measures
• Determine and deal with underlying cause
• Control of Pain and infection
• Steroid supplementation for atleast 3 days after
BP has returned to normal

Treatment
• Since bacterial infection frequently precipitates
acute adrenal crisis, broad-spectrum
antibiotics should be administered
empirically while waiting for the results of
initial cultures

UNCONSCIOUSNESS
Supine Position
Syncope - Recovery
No [Check Carotid Pulse]
Present [Sugar]
Absent – Cardiac Arrest
CPRHypoglycaemia - Recovery No [100mg Hydrocortisone]
Acute Adrenocortical Insifficiency - Recovery
No [EMS]

Prognosis
• Rapid treatment will usually be life-saving
• Acute adrenal insufficiency is frequently
unrecognized and untreated since its
manifestations mimic more common conditions
• Lack of treatment leads to shock that is
unresponsive to volume replacement and
vasopressors, resulting in death

Bibliography
•
Saladin: Anatomy & Physiology: The Unity of Form and Function, Third
Edition
•
Essentials of Anatomy & Physiology; Valerie C. Scanlon, Fifth Edition
•
Netter Atlas of Physiology
•
Current Medical Diagnosis and Treatment 2009 (McGraw-Hill, 2008)
•
Rosen.and.Barkins.5-Minute.Emergency.Medicine.Consult.(2007),.3Ed

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