Adrenal Emergencies

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Understanding Adrenal Crisis

CRITICAL ILLNESS RELATIVE ADRENAL INSUFFICIENCY

10-20% of critically ill and up to 60% of septic shock pts have corticosteroid insufficiency

  • Diagnosis:
    • Suspect with hypotension refractory to IVF and vasopressors
    • Do not check levels, treat
  • Tx
    • Hydrocortisone 200mg IV daily (can break this up to 50 q6h or even 100 q8h)

 ADRENAL INSUFFICIENCY

  • Etiology
    • Autoimmune (in US), TB (developing world), hemorrhage/necrosis (Waterhouse-Friderichsen syndrome)
    • Most common precipitant of crisis is infection- look for sources
  • Presentation:
    • Confusion/agitation, hypotension, fever, abdominal pain, nausea/vomiting/diarrhea, hyperpigmentation
    • hypoNa, hyperK, hypoglycemia, lymphocytosis, eosinophilia
  • Diagnosis
    • basal cortisol (taken 6-9AM) <3 is definite. 3-18 require further testing. >18= intact HPA axis
    • ACTH stim test AKA cosyntropin test: measure cortisol at baseline, give 250mcg IV cosyntropin/ACTH, measure cortisol at 30-60min after ACTH given. test is positive if cortisol <18
  • Tx
    • IVF with glucose (D5/0.9% at 250mL/hr)
    • Stress dose hydrocortisone 100mg IV Q8
    • Note: DEXAMETHASONE is the ONLY steroid that will not invalidate ACTH stim test, if your patient is ill, start with this at 10mg
    • When acute crisis resolved, start maintenance therapy
      • hydrocortisone 12-25mg/m2/day po
      • fludrocortisone 0.05-0.3mg po
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