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Acute Adrenal Insufficiency

Acute Adrenal Insufficiency. Alex Farhat. Objectives. Define relative adrenal insufficiency Understand who gets relative adrenal insufficiency. Understand how to manage “relative adrenal insufficiency” in the setting of sepsis. Case Problem.

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Acute Adrenal Insufficiency

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  1. Acute Adrenal Insufficiency Alex Farhat

  2. Objectives • Define relative adrenal insufficiency • Understand who gets relative adrenal insufficiency. • Understand how to manage “relative adrenal insufficiency” in the setting of sepsis.

  3. Case Problem 68 yo male with pmxh of HTN, HL and COPD presents to ER with AMS and cough with productive sputum for 1 day. T 39 degrees C, BP 70/35, HR 121, RR 21. He has been given 4L of NS and has been started on norepinephrine, with no improvement in his vitals. Which of the following next steps is most appropriate?

  4. A: Draw a random cortisol level • B: Perform a high dose ACTH stimulation test • C: Administer hydrocortisone • D: Administer hydrocortisone with fludrocortisone • E: None of the above

  5. Relative Adrenal Insufficiency • Primary, secondary, tertiary and relative adrenal insufficiency are all different etiologies that cause malfunction of the HPA axis.

  6. Relative Adrenal Insufficiency • Physiological stress activates the HPA axis. • Should theoretically increase cortisol production under normal circumstances. • However, other aspects of severe illness, as in sepsis, can alter production of cortisol. • Inflammatory cytokines and renal dysfunction are presumed causes of suppression of the HPA axis during sepsis.

  7. Diagnosing Relative Adrenal Insufficiency • ACTH simulation test and serum cortisol levels are unreliable tests for diagnosing relative adrenal insufficiency. • There is no reliable test for diagnosing relative adrenal insufficiency.

  8. Treatment in sepsis • Physicians should have a very low threshold for giving glucocorticoid (such as hydrocortisone) once vasopressors are started. • Map<65 or SBP<90. • Fludrocortisone (a mineralocorticoid) has not been shown to help in relative adrenal insufficiency.

  9. Summary • Relative adrenal insufficiency is a different phenomenon than adrenal insufficiency. • No diagnostic test is reliable for relative adrenal insufficiency. • Low threshold to treat relative adrenal insufficiency in septic patients. • Fludrocortisone has not been shown to help

  10. Case Problem 68 yo male with pmxh of HTN, HL and COPD presents to ER with AMS and cough with productive sputum for 1 day. T 39 degrees C, BP 70/35, HR 121, RR 21. He has been given 4L of NS and has been started on norepinephrine, with no improvement in his vitals. Which of the following next steps is most appropriate?

  11. A: Draw a random cortisol level • B: Perform a high dose ACTH stimulation test • C: Administer hydrocortisone • D: Administer hydrocortisone with fludrocortisone • E: None of the above

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