Postoperative Hypotension: acute adrenal crisis Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics.

Postoperative Hypotension:

acute adrenal crisis

Bradley J. Phillips, MDBradley J. Phillips, MD

Burn-Trauma-ICUBurn-Trauma-ICU

Adults & PediatricsAdults & Pediatrics

Case #1

• 21 yo morbidly obese man MVC• BP 70, P 128, RR 20• c/o chest pain and pelvic pain• PE:

– crepitus R chest wall R CT placed– dislocated R shoulder– abdominal wall contusion– pelvic tenderness

• Labs: Hct 40 ABG 7.29/42/151

Case #1

• Studies– CXR - small R PTX with CT, multiple rib fxs– Pelvis - B rami fx– Lat Csp - neg– Cystogram - normal– CT ABD - left perinephric and pelvis

hematoma, multiple pelvic fx

• IV crystalloids/blood given

Case #1

• T 39 C, SBP 90, UOP < 30 cc/hr• Resp. distress with tachypnea/hypoxia• Intubated• Started on dopamine and norepinphrine• ? Dx and plan

Case #1

• Echo = normal• PA catheter

– CI 8.5, Wedge 11, SVR 494

• Cultures sent• Exploratory laparotomy

– nonexpanding retroperitoneal hematoma

• ? Dx and plan

Case #1 - Adrenal Insufficiency

• Cortisol level drawn• Dexamethasone 10 mg IV given• Within hours, SBP > 100 off pressors , T 38C• UOP 800 cc/hr• Cortisol level 1.2• Cosyntropin stim test: baseline 1.6, 60 min.

2.3• Continued on glucocorticoid and

mineralocorticoid

Case #2

• 63 yom admitted with large cell diffuse lymphoma

• CT scan - massive retroperitoneal lymphadenopathy

• Given 4 drug chemotherapy• Developed fever 39, lethargy, and

abdominal pain• ? Dx and plan

Case #2• Exploratory laparotomy

– SB perforation from lymphoma– SB resection and primary anastomosis

• POD1 extubated and doing well• POD 2

– hypotension, tachycardia, fever, and resp. distress– CXR - diffuse pulm edema– intubated– CV collapse despite IVF and

dopamine/norepinephrine

• ?Dx and plan

Case #2

• PA catheter– CI 6, Wedge 22, SVR 350

• Repeat laparotomy performed– negative

• ? Dx and plan

Case #2 - Adrenal Insufficiency

• Cortisol level drawn• Dexamethasone 10 mg IV given• Several hours dramatic improvement

– SBP 140 and weaned from pressors– SVR 1000

• Cortisol baseline = 6, cosyntropin stim test = 7

• Hydrocortisone 100mg q 8hrs• D/C 1 month later on oral glucocorticoids

Case #3

• 57 yo m s/p XRT with recurrent invasive bladder TCC

• OR - radical cystectomy, ileal loop urinary diversion

• POD 4 – DVT L leg– started on heparin qtt– prompt decrease in swelling and pain

• POD 8 – LGI bleeding – HCT 31 to 19

Case #3• Heparin discontinued and FFP/Vit k given• Tagged red cell scan + ileoileal

anastomosis• Transfused and HCT stabilized at 32/PLT

292K• Progression of DVT

– restarted heparin for goal of 40 -50

• Developed fever 101, nausea, and LUQ pain

• PE– BS decrease at L lung base– abdomen distended and tender LUQ

• ? DX and plan

Case #3

• CXR neg, EKG neg, VQ scan neg• LFT/amylase/lipase normal• PLT decreased to 60K - heparin stopped/IVC

placed• POD 9-12

– abdominal complaints resolved– increased confused and disoriented– labs WNL with slowly resolving

thrombocytopenia– developed hypotension, tachypnea, and fever 102

Case #3

• Required intubation• Dopamine/norepinephrine qtt started• EKG and electrolytes WNL• WBC 23K• PA gram - negative• ? Dx and plan

Case #3

• Dx ( preliminary) - septic thrombophlebitis• ABX started and slight improvement• Cultures sent and subsequently neg• Continued to deteriorate with

fever/hypotension• Gallium scan - increased uptake L pelvis• Exploratory laparotomy - negative• ? Dx and plan

Case #3 - Adrenal Insufficiency

• Hydrocortisone given prior to OR• Prompt improvement• Fever resolved and BP returned to normal• Cosyntropin stim. test- low baseline, no

response• Placed on dexamethasone • Required fludrocortisone for hyponatremia

and hyperkalemia on restricted NA diet

Postoperative Hypotension

•Hemorrhage• Intravascular hypovolemia•Sepsis

• Cardiac failure• Adrenal insufficiency

ICU Adrenal disorders

• Adrenal insufficiency (AI)• Pheochromocytoma and “ crisis”• Aldosterone deficiency

Adrenal Insufficiency

• Incidence– General population 40-60/million– ICU 1-20%

• SICU 0.66%– SICU trauma 0.23%– SICU nontrauma 0.98%

• SICU– > 14 days 6%– age > 55 1.7%– > 14 days and age > 55 11%

– Blunt adrenal injury 5%

Adrenal Insufficiency - AI

• Primary

• Central

• Relative

Primary AI

• Pathological process within adrenal gland– 90% of gland destruction

• Etiology– Autoimmune - 65-80%– Infectious - 35%– Hemorrhagic

• Risk factors (Rao et al , Ann Intern Med, 1989)– coagulopathy– thromboembolic disease– postoperative state

Central AI

• Central dysfunction – pituitary (secondary)– hypothalamus (teritary)

• Etiology long-term glucocorticoid therapy– uncommon

• post-partum pituitary necrosis (Sheehan’s syndrome)

• transient ACTH deficiency (alcoholics)• pituitary radiation• empty sella syndrome

Relative AI

• Relative– increased degradation of glucocorticoids

• drugs that activate hepatic metabolism• treatment of hypothyroidism

– resistance to glucocorticoid activity• AIDS

– increased demand (stress response)• numerous ICU studies

Risk Factors - AI

• Age > 55• Malnutrition• Prolonged hospital or ICU stay• Chronic alcoholism• High APACHE score• Stress in form of trauma, surgery,

infection, and dehydration

Presentation of AI

• Non-ICU– insidious– nonspecific (weakness, wt loss, lethargy,

GI symptoms)

• ICU– acute adrenal crisis– altered by co-existing disease– usually precipitated by physical stressor

(trauma, surgery, infection, dehydration)– other causes AIDS, TB, or pituitary tumor

ICU Clinical Presentation

• Refractory hypotension• High-output circulatory failure

– CI > 4– tachycardia– low SVR with normal wedge

• Electrolytes disturbances– high K , low Na, and low glucose

• Febrile (> 39C)• Mental status changes• Dehydration• GI disturbances

“Clues” to AI

• History– other endocrine abnormalities– family h/o endocrine abnormalities

• Eosinophilia

AI Differential Diagnosis

• Sepsis• Neurogenic shock• Overdose of vasodilator• Severe anemia• AV shunt• Thyrotoxicosis• Beriberi• Pregnancy

Hypothalamus-Pituitary-Adrenal Axis

Cortisol - 10 mg/d

-

-

ACTH +

CRH +

HPA Axis Assessment - Tests

• H-P Axis and Adrenal– Low-dose ACTH stimulation (1 ug)

• Adrenal only– Short ACTH stimulation test (250 ug)

• H -P Axis only– Insulin-induced hypoglycemia test– Metyrapone– CRH stimulation

Laboratory Assessment

• Random cortisol level– draw before steroids given– draw between 6-8 am – decadron generally consider not cross-reactive– positive if < 10 in normal or < 15 in critically ill– 10-20 indeterminant

• Cosyntropin testing• Corticotropin-releasing hormone test (CRH)• Plasma renin and aldosterone measurements

Cosyntropin stimulation test

• Standard short– baseline cortisol level– 0.25 mg cosyntropin with level 60 minutes later– peak > 20 or rise of 7 in critically ill

• Low-dose short ( more sensitive for central)– more accurate and physiologic– same as standard but only 1 ug dose

• Long – differentiation of primary vs central– replaced by ACTH measurement

HPA Axis Assessment:Test Summary

Diagnosis - AI in Critical illness

Adrenal deficit BaselineACTH

Severe < 10none

Moderate 10-19 <30Mild 20-30 <30None > 30

>>30

Treatment

• Hemodynamically unstable– Baseline cortisol– Treat with Hydrocortisone 100 IV bolus and q8– +/- cosyntropin testing– Isotonic IVF with D5– treat underlying disease or precipitating factors

• Hemodynamically stable– same as above – cosyntropin testing

Treatment - Steroids• Hydrocortisone

– provides glucocorticoid and mineralocorticoid– physiological doses

• max 300 mg/day– normal daily adrenal output

• AM 25 mg /PM 12..5 mg

• Dexamethasone– not cross-reactive with cortisol assays– no mineralocorticoid activity– useful while diagnostic testing being completed

• Fludrocortisone (Florinef)– uncommonly required for mineralocorticoid

activity

Steroid and Potency

Glucocorticoid vs Mineralocorticoid

• Steroid Glucocorticoid Mineralocorticoid

Hydrocortisone 1 1Prednisolone 4 0.7Dexamethasone 40 2Aldosterone 0.1 400Fludrocortisone 10 400

Potential for HPA Suppression

• Higher risk for suppression– higher glucocorticoid potency– short frequency of dosing– evening dosing– systemic therapy– duration > 1 week

Outcome

• Untreated = 100% mortality• Treated in critically ill = 50% mortality• Cortisol level

– positively correlated to severity of illness– negatively correlated to survival

Prevention

• Susceptible within 1-2 years of high dose glucocorticoids treatment

• Presurgical screening– elderly patients– prolonged previous hospitalizations– malnourished or alcoholic patients– risk factors for adrenal insufficiency

• prednisone doses > 5 mg/d• subnormal ACTH-stimulation test• previous adrenal insufficiency

Prophylactic Steroid Therapy

• Universal coverage most common• Lowest possible dose (perioperative)

– Glowniak et al , Surgery, 1997• prednisone maintenance dosing only

– Salem et al, Ann Surgery, 1994• minor surgery (hernia) = 25 -50 mg HC x 1 d• moderate (chole, TAH) = 50 -100 mg HC/d x 1-

2• major (Whipple, CABG) = 100-150 mg HC/d x

2-3 d

• Decreased frequency ( qod if possible)• Am dosing (1/2 PM dosing only if needed)

Postoperative Hypotension:

acute adrenal crisis

questions…?Bradley J. Phillips, MDBradley J. Phillips, MD

Burn-ICUBurn-ICUShriners Hospital for ChildrenShriners Hospital for Children