Acute Adrenal Insufficiency
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Transcript Acute Adrenal Insufficiency
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Adrenal Insufficiency (AI) in
the Septic Patient
Fady Youssef, MD PGY-2 2014
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Objectives
Define adrenal insufficiency
Understand who gets Relative adrenal insufficiency
Review the current evidence
Understand how to manage “Relative adrenal insufficiency” in the
setting of sepsis.
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Case Problem
68 yo male with PMH 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?
A: Draw a
B:
random cortisol level
Perform a high dose ACTH stimulation test
C: Administer
hydrocortisone
D: Administer
hydrocortisone with fludrocortisone
E:
None of the above
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Definition
Acute reversible dysfunction of the HPA axis in the setting of
physiologic stress (e.g. sepsis, intra/post operative state)
It is estimated that ___ % of critically ill patients suffer from
HPA axis dysfunction
30%
Symptoms of AI
shock, abdominal pain, fever, nausea and vomiting, electrolyte
disturbances and, occasionally, hypoglycemia
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Who gets AI?
Any patient in the setting of physiologic stress
Etiology:
Adrenal ACTH resistance
Decreased responsiveness of the target tissue to
glucocorticoids (GC)
Secondary AI: 2/2 chronic steroid therapy (dose dependent)
Certain meds: Etomidate, Phenytoin, Ketoconazole
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HPA Axis
2ry AI
Where is the dysfunction occurring in secondary AI?
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Diagnosing Relative Adrenal
Insufficiency
Diurnal variation is LOST during physiological stress
Lab assays of plasma cortisol concentration and ACTH stimulation test
are unreliable in critically ill patients
Random serum cortisol: Varies widely in critically ill patients.
Increased mortality with both very low and very high cortisol levels
There is are no reliable tests for diagnosing relative adrenal
insufficiency.
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So when to start steroid therapy?
Low MAP or SBP: requiring vasopressors
All meta-analyses confirmed improved shock reversal with
low-dose corticosteroid use (trials listed below for further
reference)
Response to vasopressors is irrelevant to whether steroids should be
started or not
Responsiveness is defined as: maintaining MAP > 65 mmHg
without vasopressor use within 1 day of starting hydrocortisone
Don’t delay treatment for ACTH stim test
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Treatment in sepsis
Hydrocortisone: total of 200 – 300 mg over 24 hrs
50 – 100 mg q6-8h for 5-7 days with taper
Patients receiving higher doses of steroids had worse outcomes (citation
below)
Fludrocortisone (a mineralocorticoid) has not been shown to help in
relative adrenal insufficiency.
Hydrocortisone seems to have sufficient mineralocorticoid activity
COIITSS trial
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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?
A: Draw a
B:
random cortisol level
Perform a high dose ACTH stimulation test
C: Administer
hydrocortisone
D: Administer
hydrocortisone with fludrocortisone
E:
None of the above
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Summary
No diagnostic test is reliable for relative adrenal insufficiency.
Low threshold to treat relative adrenal insufficiency in patients with
septic shock
Use low dose hydrocortisone/physiologic dosing for a limited time
Fludrocortisone has not been shown to help in relative AI
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Interested? Here is more …
HPA axis – Normal response
Physiological stress activates the HPA axis which in turn increases
serum cortisol levels
Serum Cortisol levels remain elevated during stress due to several
factors:
Reduced activity of cortisol metabolizing enzymes
Renal dysfunction prolonging the half life
Decrease in cortisol-binding globulin and albumin which brings > 90% of
cortisol
Inflammatory cytokines: Increase GC receptor affinity and increase the
peripheral conversion of precursors to cortisol