Endocrine and Metabolic 1:
Adrenal Crisis Portal
(Adrenal Failure/Adrenocortical Insufficiency/Addisonian Crisis)
Introduction/Etiology
Adrenal crisis (also referred to as Addisonian crisis) is potentially
fatal if not rapidly recognized and treated. Adrenocortical
insufficiency (AI) may result from primary adrenal gland disease when
more than 90% of the adrenal gland has been destroyed by some
infiltrative, infectious, immunologic process such as AIDS, metastatic
disease to the adrenal gland, or disseminated tuberculosis. Secondary
AI is due to a deficiency in the adrenocorticotropic hormone (ACTH)
from the pituitary or the corticotropin releasing hormone (CRH) from
the hypothalamus. This condition usually occurs secondary to exogenous
glucocorticoid withdrawal.
Any patient who is seriously ill with hypotension and not responding to
usual modes of treatment such as volume expansion or vasopressor
agents, who has received glucocorticoids within the past year, who has
cancer, or who has AIDS must be considered as potentially having AI
resulting in adrenal crisis.
Signs and Symptoms
Although the manifestations of AI are non-specific, most patients
exhibit hypotension, weakness, fatigue, anorexia, nausea/vomiting, and
weight loss. Hyperpigmentation is common in patients with chronic AI.
Laboratory Findings
The diagnostic endocrine tests are usually not immediately available at
the time of an adrenal crisis. Most patients with AI do have dilutional
hyponatremia. Those with primary adrenal failure also frequently have
hyperkalemia due to the deficiency in aldosterone in addition to the
cortisol deficiency. Hypoglycemia is present in about 50% of patients
with AI.
Treatment Regimens for
Adrenocortical Insufficiency/Adrenal Crisis
Consider treatment for adrenal insufficiency in any
hypotensive,
critically ill patient who is not responding to other appropriate
treatment modalities.
- Treatment if the Diagnosis of Adrenal Failure is
Known:
- Administer hydrocortisone 100 mg IV every 8 hours.
- Rapidly infuse D5 with 0.9% NS IV
until hypotension is corrected. At least 2 L of IV solution is usually
needed in the first 6 hours of treatment. Do not give excess free water
- Decrease the dosage of hydrocortisone IV gradually (over several days) as the symptoms and precipitating illness resolve. Change to oral maintenance therapy when appropriate
- Mineral corticoid replacement is not needed until the dose
of
hydrocortisone is < 100 mg per day.
- Treatment if Adrenal Failure Has Not Been Established and
Needs to
be Confirmed:
- Draw blood for measurement of cortisol, aldosterone, ACTH, and routine chemistries.
- Administer dexamethasone 10 mg IV.
- Rapidly infuse D5 in 0.9% NS IV until hypotension is corrected. At least 2 L of IV solution is usually needed in the first 6 hours of therapy. Do not give excess free water.
- Perform a short ACTH stimulation test (ie, give Alpha-1, 24 ACTH [Cortrosyn] 250 µg IV or IM). Draw a plasma cortisol level 30 minutes later.
- After drawing the 30-minute cortisol level, begin hydrocortisone 100 mg IV every 8 hours and proceed as if the adrenal failure diagnosis is known.
- Investigate for other precipitating illnesses; treat
appropriately.
- Initial Treatment for Patients with Known AI or Steroid Use
Within
the Past Year During Major Stresses such as Trauma, Acute MI, or
Emergency Surgery:
- Immediately give 100 mg hydrocortisone IV.
- Maintain a continuous infusion of IV hydrocortisone at a rate of 10 mg per hour until the patient is stable or out of the PAR.
- Continue hydrocortisone 100 mg IV every 8 hours and taper
and/or
change to oral steroids over the next 3 to 5 days as dictated by the
patient’s condition and circumstances.
- Steriod Coverage for Elective Major Surgery in Patients
Requiring
Steroid Preps:
- Give hydrocortisone 100 mg IV 8 hours before surgery.
- Give hydrocortisone 100 mg IV 1 hour before surgery.
- Maintain a continuous infusion of hydrocortisone IV at a rate of 10 mg per hour during surgery and until the patient is out of the PAR.
- Continue hydrocortisone 100 mg IV every 8 hours and taper and/or change to oral steroids over the next 3 to 5 days as dictated by the patient’s condition and circumstances.