Adrenal Insufficiency and adrenal crisis

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Adrenal Insufficiency and adrenal crisis. Pongtorn Siritheanchai. Etiology and pathogenesis. 1.primary adrenal insufficiency adrenal cortex addisons dz,granulomatous idiopathic autoimmune tumor,infection,Sx - PowerPoint PPT Presentation

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  • Adrenal Insufficiencyand adrenal crisisPongtorn Siritheanchai

  • Etiology and pathogenesis1.primary adrenal insufficiency adrenal cortex addisons dz,granulomatous idiopathic autoimmune tumor,infection,Sx2.Secondary adrenal insufficiencypituitary gl. ACTH tumor,infection,sheehans syndrome 3.Tertiary adrenal insufficiency external steriod HPA axis

  • Clinical manifestration primary glucocorticoid,mineralocorticoid,androgen secondary tertiary glucocorticoid GI N/V Hypotention,syncope primaryHypoglycemia secondary,tertiary hypotention,dehydrate

  • Clinical manifestrationHyperpigmentation primary ACTH Loss of pubic and axillary hair Neuro : confusion,delirium,stupor,depression,psychosissecondary tertiary primary hyperpigmentationDehydration,hypotention Hypoglycemia

  • Adrenal crisisSepsis,Sx stress,GI upsetAcute hemorrhagic destruction : in children ass.with septicemia with pseudomonas or meningococemia,in newborn ass.with birth trauma,in adult ass with anticoagulant therapy,in pregnancy ass with idiopathic adrenal vein thrombosis,rapid withdrawal of steroid

  • Adrenal crisisNausea,vomittingAbd.painFeverLethargy,somnolanceHypovolumic,BP drop primary mineralocorticoid seconday,tertiary glucocorticoid vascular tone dehydration

  • Diagnosis Tests1.Basal Cortisol secretion 6-8.00. 5 10 clinical 20 rule out 2.Random cortisol level severe stress 13 20 3.Rapid ACTH stimulation test cosyntropin 250 Ug iv or im cortisol 30 60 20 13

  • Localizing test1.Basal plasma ACTH2.Prolong ACTH stimulation test cosyntropin 800 ug iv drip in 48 hr 24 hr-urine 2 days 17-hydroxy-corticosteroid serum cortisol primary 17-hydroxy-corticosteroid 5 mg/d cortisol 20ug/dl3.CRH test secondary tertiary

  • Treatmentadrenal crisis0.9%NSS or 5%DNSS 2-3L in the first few hrHydrocortisone 100mg iv push and then continuous drip at rate 10mg/h or 100mg iv q 6 hrFind and Correct precipitateting cause Following improving,taper off steroid in the next few day to maintainance level 3 In primary steroid

  • Maintainance TherapyHydrocortisone 20-30mg/d,take with meal or antacid, 2/3 (6-8) 1/3 (13-15)Some Pt exhibit insomnia,irritability,mental excitement,dosage should be reduceDexa 0.5-0.75mg/d or Pred 5-7.5 mg/d clinical improve,decrease hyperpigmentation,morning plasma ACTHFudrocortisone in primary adrenal insuff 0.1-0.2 mg/d and intake sodium 3-4g/dAdequacy of mineralocorticoid assess by BP and Elyte

  • ComplicationGlucocorticoid : gastritis and other are rare in dosage recommendMineralocorticoid :Hypo K,HT,cardiac enlargement,CHF due to Na retention

  • Special therapeutic problemIntercurrent illness,esp fever,dose of hydrocortisone should be doubleWith severe illness 75-150mg/dBefore Sx or dental extract should be supplementFludrocortisone to increase in strenuous exercise,hot weatger,GI upsetMineralocorticoid is unnecessary at hydrocortisone dose>100mg/d

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