Acute Adrenal Insufficiency

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Slide 1 : Acute Adrenocortical Insufficiency Akase E.I. Endocrine unit Presentation.
Slide 2 : SYNOPSIS Introduction Causes Features Treatment Conclusion
Slide 3 : Introduction A life-threatening condition resulting from failure of production of adrenal cortical hormones, mainly cortisol and aldosterone. A medical emergency which is often elusive, that may result in severe morbidity and mortality when undiagnosed or ineffectively treated.
Slide 4 : Diff from Addison’s disease, which is a syndrome of long-term primary adrenal insufficiency that develops over months to years. Causes of Addison’s dx include; -Autoimmune adrenalitis -Infectious adrenalitis; TB, Fungi, Syphilis, HIV. -Adrenal hemorrhage or infarction -Infiltration; Cancer, sarcoidosis, Amyloidosis. -Drugs ;Keto, Rif, Phenytoin ,Barbiturates, Megestrol acetate, aminoglutethimide, etomidate, metyrapone, suramin, mitotane -Others; CAH, adrenoleukodystrophy
Slide 5 : Causes: Acute Insufficiency Adrenal crisis Acute hemorrhagic destruction -Infection -Anticoagulants & Bleeding disorders -Others; Preg, idiopathic adrenal vein thrombosis, complication of venography. Rapid withdrawal of steroids CAH or Low reserve on drugs e.g. Rif, Phenytoin, mitotane, ketoconazole.
Slide 6 : Features Abdominal pain Salt craving Severe vomiting and diarrhea, with dehydration Confusion, psychosis, slurred speech Severe lethargy Hypovelemia and Shock (In severe cases) Fever Convulsions ±Pigmentation, Vitiligo, Wt loss. High index of suspicion may be required!
Slide 7 : Precipitants Sepsis Trauma Surgery Burns Acute fluid losses Hx of steroid use Other drugs; Anticoagulants, anti steroids, Hx of pregnancy, PPH.
Slide 8 : Sepsis AND Adrenal Insufficiency In acute illness, cortisol ? 4-6times & diurnal variation abolished. Pts who dev’p septic shock ± have underlying relative adrenal insufficiency Annane et al's landmark 2002 study found a very high rate, i.e., 76% of all enrolled patients with septic shock. They do better if treated with a week course of steroids, then tailored.
Slide 9 : Investigations Serum chemistry; ?Na, ?K, Acidosis, hypoglycemia. Serum cortisol: ?15-20 mcg/dL in severe stress or after ACTH stimulation is indicative of adrenal insufficiency. ACTH test (diagnostic): 250 mcg IV, ??9mcg/dL is considered diagnostic of adrenal insufficiency. FBC; Normo, lymphocytosis, eosinophilia. Cultures Underlying cause; RVS, CXR, Auto Abs, e.t.c.
Slide 10 : Treatment Maintain airway, breathing, and circulation in patients with adrenal crisis. Use aggressive volume replacement therapy (5%DS). Correct electrolyte abnormalities Administration of glucocorticoids in supraphysiologic or stress doses is the only definitive therapy e.g. Hydrocort 100mg 6hrly ±Fludrocortisone 0.1mg daily ±Pressors (e.g., dopamine, norepinephrine) ? underlying cause
Slide 11 : Conclusion Acute adrenal insufficiency has been described as ‘ the unforgiving master of non specificity and disguise’ Can be fatal, especially when the diagnosis is missed. Timely intervention is crucial. Any delay in management while waiting for diagnostic confirmation cannot be justified. A high index of suspicion must be maintained.

 


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