LITERATURE
CRITICAL ILLNESS RELATIVE ADRENAL INSUFFICIENCY
10-20% of critically ill and up to 60% of septic shock pts have corticosteroid insufficiency
- Diagnosis:
- Suspect with hypotension refractory to IVF and vasopressors
- Do not check levels, treat
- Treatment
- Hydrocortisone 200mg IV daily (FIRST DOSE 100mg – can then break this up to 50 q6h or even 100 q8h)
ADRENAL INSUFFICIENCY
- Etiology
- Autoimmune (in US), TB (developing world), hemorrhage/necrosis (Waterhouse-Friderichsen syndrome)
- Most common precipitant of crisis is infection- look for sources
- Presentation
- Confusion/agitation, hypotension, fever, abdominal pain, nausea/vomiting/diarrhea, hyperpigmentation
- hypoNa, hyperK, hypoglycemia, lymphocytosis, eosinophilia
- Diagnosis
- basal cortisol (taken 6-9AM) <3 is definite. 3-18 require further testing. >18= intact HPA axis
- ACTH stim test AKA cosyntropin test: measure cortisol at baseline, give 250mcg IV cosyntropin/ACTH, measure cortisol at 30-60min after ACTH given. test is positive if cortisol <18 (or has not changed more than 9)
- Treatment
- Resuscitate with 0.9%NS, IVF with glucose (D5/0.9% at 250mL/hr)
- Stress dose hydrocortisone 100mg IV x1 (then 50mg q6h) PREFERRED PHARMACOKINETICS OVER OTHER STEROIDS (Fludrocortisone not required if hydrocortisone dose >50mg per day)
- Alternates – Methylprednisolone 40mg q24h; Prednisolone 25mg q8h for 24 hours then 50mg q24h
- Note: DEXAMETHASONE is the ONLY steroid that will not invalidate ACTH stim test, if your patient is ill, start with this at 10mg
- When acute crisis resolved, start maintenance therapy
- hydrocortisone 12-25mg/m2/day po
- fludrocortisone 0.05-0.3mg po