This document summarizes a lecture on the adrenal gland and adrenal insufficiency. It discusses: 1) The anatomy and physiology of the adrenal gland, including embryology, histology, and locations of extra-adrenal tissue. 2) Types of adrenal insufficiency including primary (defects in steroidogenesis or diseases of the adrenal gland) and secondary (suppression of ACTH production). 3) Adrenal insufficiency in critically ill patients caused by reversible dysfunction of the HPA axis during sepsis or systemic inflammatory response. 4) Diagnosis of adrenal insufficiency using morning cortisol/ACTH levels and stimulation tests.

1. Adrenal gland
Dr. Khaled Alsharafy
Supervised by
- Ass.Prof Waleed Ghialan
- Assist.Prof Loai Alqobati

2. In this lecture
•

3. Anatomy and physiology

4. Anatomy
Sabiston textbook of surgery 21st edition

5. Embryology

6. Extra-adrenal cortical and medullary tissue

7. Histology

8. physiology

9. Adrenal insufficieny

10. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Primary adrenal insufficiency
Secondary adrenal insufficiency
Adrenal insufficiency in critically ill
patient

11. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Primary adrenal insufficiency
Defective
steroidogenesis
Congenital
adrenal
dysgenesis
Adrenal
distraction

12. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Primary adrenal insufficiency
Adrenal
distraction
Autoimmune
Infection ( TB, Fungal, viral)
Metastatic cancer
Adrenal hemorrhage

13. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Secondary adrenal insufficiency
Suppression of
ACTH
Panhypopituitarism

14. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Secondary adrenal insufficiency
Suppression
of ACTH
Pharmacological steroid
withdrawal
Surgical treatment of
Cushing

15. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Secondary adrenal insufficiency
Suppression
of ACTH
Pharmacological
steroid withdrawal
High supraphysiologic
dose for more than 5
days
Low supraphysiologic
dose for more than 3
weeks

16. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Secondary adrenal
insufficiency
High supraphysiologic dose
prednisone >20mg

17. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Adrenal insufficiency in critically ill patient
Reversable
dysfunction of
the HPA axis
SIRS
sepsis

18. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency
Adrenal insufficiency in critically ill patient
In septic shock
corticosteroid administration associated with a reduction in
30-day mortality (1.8% absolute risk reduction) and faster
shock reversal
Sabiston textbook of surgery 21st edition

19. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (diagnosis)
8 a.m serum or salivary cortisol
level
ACTH stimulation test
8 a.m serum ACTH

20. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (diagnosis)
SYMPTOMS

21. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (diagnosis)
Sabiston textbook of surgery 21st edition

22. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (diagnosis)
Sabiston textbook of
surgery 21st edition

23. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (management)
adrenal insufficiency
Adrenal crisis
Peri-operative

24. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (management)
adrenal insufficiency
replace physiologic glucocorticoid and mineralocorticoid levels
- prednisone at a dosage of 5 mg/day
- fludrocortisone, 0.1 mg/day

25. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (management)
Adrenal crisis
The treatment of adrenal crisis
centers around large-volume (1–2 L) intravenous resuscitation
with isotonic saline and glucocorticoid administration in the form
of hydrocortisone (100 mg intravenous bolus followed by 75 mg
every 8 hours) or dexamethasone (4 mg intravenously every 24
hours). Dexamethasone is long acting and carries the advantage of
not interfering with biochemical assays of endogenous glucocorticoid production. Ironically,
mineralocorticoid replacement is not
an early priority because the sodium- and fluid-retaining effects of
mineralocorticoids are not manifested until several days after administration. Fluid and
electrolyte balance can be rapidly achieved
by saline infusion.

26. ‫الورشة‬ ‫محاور‬
5Ps
Adrenal insufficiency (management)
Peri-operative
Sabiston textbook of surgery 21st edition

27. Primary Hyperaldosteronism

28. Primary Hyperaldosteronism
black
Red
Yellow
Green

29. Why the triage ?

30. ‫الورشة‬ ‫محاور‬
5Ps
Aim of triage
DO THE MOST GOOD FOR
MOST PATIENTS USING
AVAILABLE RESOURCES

31. ‫الورشة‬ ‫محاور‬
5Ps
Right Patient
Right Place
Right Time
Right Care
To get 4 Rights
Aim of triage

32. Triage categories

33. Triage categories
black
Red
Yellow
Green

34. Triage categories

36. Triage protocol

37. Triage responsibility
• Senior
• Experienced
• Control of
emotion

38. Triage steps
Ability to walk
Breathing
Respiratory rate
Perfusion
Mental status

39. Triage steps
Patient able
to walk Minor
Breathing
Yes
No

40. Triage steps
Breathing
spontaneously
Breathing
spontaneously
RR
apnea
Position airway
Yes
No
immediate
Expectant
Yes

41. Triage steps
RR
Perfusion
> 30
<30
immediate

42. Triage steps
Perfusion
Mental
status
Capillary refilling time > 2 immediate
Radial pulse absent

43. Triage steps
Mental
status
Delayed
immediate
Doesn't obey command

44. Triage steps
Expectant
• Apnea despite
airway positioning
• Not expected to
survive

45. Triage steps
• level of consciousness
• Temporary apnea
• RR> 30
• Radial pulse absent
• Capillary refill time <2
immediate

46. Triage steps
• Has no criteria of
immediate
• Unable to walk
Delayed

47. Triage steps
Able to walk
Minor

48. Who should be
treated 1st ?

49. Who should be treated 1st ?
crush limb injury
Breath Spontaneously ,
conscious , RR= 25 ,
PR= 120
chest wound , dyspnea
conscious , Breath
Spontaneously , RR= 35
1 2

50. Screaming, able to walk
, conscious RR= 24
Head injury , brain
tissue out , coma ,
apnea
Who should be treated 1st ?
4
3

51. 4- head injury
3- walking patient
Who should be treated 1st ?
2- chest pain
1- limb injury

52. Questions ?