Adrenal insufficiency & Adrenal Crisis

Clinic A/P, adults, Clinic A/P, Peds, Hospital A/P, Adults, Hospital A/P, Peds

H&P performed.
Definition: Adrenal crisis = acute adrenal insufficiency. It is a life-threatening emergency that requires immediate treatment.
Pt in adrenal crisis, not just adrenal insufficiency.
S/Sx of adrenal crisis reviewed.
DDx of adrenal crisis.
Pathophysiology reviewed.
Will distinguish primary, secondary, and tertiary causes.
Labs:
Imaging:
BMP usually shows a slightly low sodium level and a slightly high potassium level.

Treatment of adrenal crisis in the Emergent Setting
-Two large bore IV accesses
-Labs: Stat CMP (electrolytes + glucose) and CBC. Routine Plasma cortisol and ACTH. Will not wait for labs to start treatment.
–IV Fluids: Give 2-3 Liters of NS or D5 NS as boluses.
-Monitoring: Frequent hemodynamic and electrolyte monitoring to avoid iatrogenic fluid overload.
–Rx: Dexamethasone 4 mg IV bolus over one to five minutes and every 12 hours thereafter. For patients who have not been diagnosed with Addison’s disease yet, Dexamethasone is the drug of choice because it does not interfere with the measurement of plasma cortisol.
-If Dexamethasone is not available, use Hydrocortisone, 100 mg IV immediately and every 6 hours thereafter.
-Supportive therapy as needed.
Electrolyte abnormalities may include hyponatremia, hyperkalemia or rarely hypercalcemia. Hyponatremia is rapidly corrected by cortisol and volume repletion.

Treatment of adrenal crisis after the patient has been stabilized.
-Continue IV Fluids at a slower rate for the next 24-48 hours.
-Assess and treat possible infectious precipitating causes of the adrenal crisis.
-Do a Cosyntropin (ACTH) stimulation test to confirm the diagnosis of adrenal insufficiency in patient’s who don’t have a known diagnosis of Adrenal Insufficiency.
-Diagnose the adrenal insufficiency and try to find the cause.
–Taper parenteral steroids over 1 to 3 days to oral steroid maintenance dose (if pt’s illness improves)
-Mineralocorticoid replacement: Start fludrocortisone 0.1 mg PO daily when the saline infusion is stopped.

Important Links

  • Steroid Conversion.
  • Patient with Adrenal Crisis.
  • The Difference Between Adrenal Insufficiency and Adrenal Crisis.
  • Pts admitted into the hospital are likely going to be having an adrenal crisis (see s/sx), not just adrenal insufficiency.
  • Understanding Adrenal Insufficiency and Adrenal Crisis.
  • Good article on “Adrenal Crisis”.
  • Primary adrenal insufficiency. “In Western countries, autoimmunity is responsible for 90% of these cases. Because the corticotropin (ACTH) stimulation test has a higher degree of sensitivity and specificity than morning cortisol and ACTH concentrations, it is the preferred test in all patients with possible primary adrenal insufficiency. Serum aldosterone paired with plasma renin activity is used to screen for adrenal hyperplasia in hypertensive patients and also for establishing the existence of mineralocorticoid insufficiency in patients with PAI. Once the diagnosis is established, 21-hydroxylase antibodies and 17-hydroxylase progesterone levels are used to determine the etiology of PAI.” ABFM critique.

 

 

Further Reading

J Clin   Endocrinol Metab 2016;101(2):364-389. Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline.

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