Top Banner
Dr. Armaan Singh Dr. Armaan Singh
11

Relative adrenal insufficiency

Jul 24, 2015

Download

Health & Medicine

Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Relative adrenal insufficiency

Dr. Armaan Dr. Armaan SinghSingh

Page 2: Relative adrenal insufficiency

Define relative adrenal insufficiency

Understand who gets relative adrenal insufficiency.

Understand how to manage “relative adrenal insufficiency” in the setting of sepsis.

Objectives

Page 3: Relative adrenal insufficiency

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?

Case Problem

Page 4: Relative adrenal insufficiency

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

Page 5: Relative adrenal insufficiency

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

Relative Adrenal Insufficiency

Page 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.

Relative Adrenal Insufficiency

Page 7: 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.

Diagnosing Relative Adrenal Insufficiency

Page 8: Relative adrenal insufficiency

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.

Treatment in sepsis

Page 9: Relative adrenal insufficiency

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

Summary

Page 10: Relative adrenal insufficiency

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?

Case Problem

Page 11: Relative adrenal insufficiency

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