CURRENT Essentials of Critical Care.pdf

Chapter 12 Endocrine Problems 179Adrenal Insufficiency■ Essentials of Diagnosis• Weakness, nausea, vomiting, abdominal pain, fever• Hypotension from hypovolemia, impaired vascular response tocatecholamines, loss of inotropic effects of cortisol• Altered mental status and confusion may be present• Hyperpigmentation of skin and mucous membranes in primaryadrenal insufficiency• Hyponatremia, hyperkalemia, hypoglycemia, azotemia, hypercalcemia,eosinophilia, lymphocytosis• Serum cortisol 20 g/dL makes diagnosis unlikely• ACTH stimulation test: increment of 7 g/dL or peak cortisollevel 17 g/dL excludes adrenal insufficiency• Low to absent serum cortisol, elevated ACTH, abnormal ACTHsimulation test in primary adrenal insufficiency• Suspect in anyone taking 30 mg of hydrocortisone per day (orequivalent) for more than 3 weeks in past 1 year• Etiologies of acute adrenal insufficiency: trauma; surgical stress;hemorrhage; infection; hypoperfusion; drugs; autoimmune; uncontrolledor poorly controlled chronic adrenal insufficiencywith precipitating event■ Differential Diagnosis• Sepsis • Salt wasting nephropathy• Hypovolemia • Medications• Metastatic cancer • Acute abdomen• Secondary adrenal insufficiency: pituitary or hypothalamic disorders■ Treatment• Immediately treat with intravenous hydrocortisone when suspected;may use dexamethasone if ACTH stimulation test delayed• Add mineralocorticoid replacement with fludrocortisone if dexamethasoneis used; not needed when 50 mg/d hydrocortisoneadministered• Correct hypovolemia and electrolyte abnormalities• Monitor and infuse glucose if hypoglycemic• May require vasopressors for blood pressure support• Consider empiric antibiotic therapy if infection suspected• Identify and treat precipitating event■ PearlDespite aggressive volume resuscitation and vasopressor use, patientswith acute adrenal insufficiency may remain hypotensive until corticosteroidreplacement has been administered.ReferenceCooper MS et al: Corticosteroid insufficiency in acutely ill patients. N Engl JMed 2003;348:727. [PMID: 12594318]