Neurosurgery notes/Other specialities/ITU/Endocrine/Addisonian crisis

Addisonian crisis

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Endocrine

Definition

  • Adrenal crisis or acute adrenal insufficiency, is an endocrinologic emergency with a high mortality rate secondary to physiologic derangements from an acute deficiency of the adrenal hormone cortisol, requiring immediate recognition and treatment to avoid death

Normal

  • Under normal, basal conditions, the zona fasciculata of the adrenal cortex secretes
    • Cortisol
      • 15–25mg/day
      • Hydrocortisone is the name for the identical pharmaceutical compound for administration
      • Half-life of ≈ 90minutes
      • CRH → ACTH → Cortisol
    • Corticosterone
      • 1.5–4mg/day
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Aetiology

Primary Adrenal Insufficiency (Addison disease)

  • Autoimmune Adrenalitis
  • Medication-Induced
    • Ketoconazole
    • Rifampin
    • Phenytoin
    • Mitotane
    • Immunotherapy with a checkpoint inhibitor
    • Diuretics
  • Infiltrative diseases
    • Sarcoidosis
    • Amyloidosis
    • Hemochromatosis
  • Infectious
    • Most commonly due to an acute illness from a viral or bacterial infection
    • Tuberculosis
    • HIV/AIDs
    • CMV
  • Adrenal hemorrhage
    • Waterhouse-Friderichsen Syndrome
  • Other:
    • Trauma
    • Pregnancy
    • Sepsis
    • Myocardial infarction
    • Physical overexertion and dehydration
    • Surgery
    • Other endocrinopathies (DKA, thyrotoxicosis, myxedema coma)

Secondary Adrenal Insufficiency

  • Iatrogenic after the rapid withdrawal of corticosteroids without tapering
    • Oral and inhaled steroids
  • Pituitary causes
    • Pituitary adenoma
    • Infiltrative disorders
    • Lymphocytic hypophysitis
    • Sheehan's syndrome
    • Pituitary apoplexy
    • Trauma

Symptoms of adrenal insufficiency (AI)

  • Fatigue
  • Weakness
  • Arthralgia
  • Anorexia
  • Nausea
  • Hypotension
  • Orthostatic dizziness
  • Hypoglycaemia
  • Dyspnoea
  • Addisonian crisis
    • If severe; with risk of death

Replacement therapy

  • In primary adrenocortical insufficiency (Addison’s disease), both glucocorticoids and mineralocorticoids must be replaced.
  • In secondary adrenal insufficiency caused by deficient corticotropin (ACTH) release by the pituitary, mineralocorticoid secretion is usually normal and only glucocorticoids need to be replaced.
  • Equivalent corticosteroid dosesᵃ
      • Steroid: generic (proprietary)
      Equiv dose (mg)
      Route
      Dosing
      Mineralocorticoid potency
      Oral dosing forms
      Cortisone acetate
      25
      PO, IM
      2/3 in AM, 1/3 in PM
      2+
      Tabs: 5, 10 & 25 mg
      Hydrocortisone AKA cortisol (Cortef®)
      20
      PO
      2/3 in AM, 1/3 in PM
      2+
      Tabs: 5, 10 & 20 mg
      (Solu-Cortef®)
      20
      IV, IMᵇ
      2/3 in AM, 1/3 in PM
      2+
      ㅤ
      Prednisone
      5
      PO only
      Divided BID-TID
      1+
      Tabs: 1, 2.5, 5, 10, 20, 50 mgᶜ
      Methylprednisolone
      4
      PO, IV, IM
      ㅤ
      0
      Tabs: 2, 4, 8, 16, 24, 32 mgᵈ
      Dexamethasone
      0.75
      PO, IV
      Divided BID-QID
      0
      Scored tabs: 0.25, 0.5, 0.75, 1.5, 4, 6 mg
    • ᵃ Doses given are daily doses. Steroids listed are used primarily as glucocorticoids: equivalent glucocorticoid PO or IV dose is given; IM may differ.
    • ᵇ IM route recommended only for emergencies where IV access cannot be rapidly obtained.
    • ᶜ Sterapred Uni-Pak® contains 21 tabs of 5 mg prednisone and tapers dosage from 30 to 5 mg over 6 days; “DS” contains 10 mg tabs and tapers from 60 mg to 10 mg over 6 days; “DS 12-Day” contains 48 10 mg tabs and tapers from 60 mg to 20 mg over 12 days.
    • ᵈ Medrol Dosepak® contains 21 tabs of 4 mg methylprednisolone and tapers dosage from 24 mg/d to 4 mg/d over 6 days.
  • Physiologic replacement (in the absence of stress) can be accomplished with either:
    • Hydrocortisone:
      • 20mg PO q AM and 10mg PO q PM
    • Prednisone:
      • 5mg PO q AM and 2.5mg PO q PM
    • Cortisol + cortisone
      • Are useful for chronic primary adrenocortical insufficiency or for Addisonian crisis.
      • Because of mineralocorticoid activity, use for chronic therapy of other conditions (e.g. hypopituitarism) may result in salt and fluid retention, hypertension, and hypokalemia.

Steroid stress doses

  • During physiologic “stress” the normal adrenal gland produces ≈ 250–300mg hydrocortisone/day.
  • With chronic glucocorticoid therapy (either at present, or within last 1–2 yrs), suppression of the normal “stress-response” necessitates supplemental doses.
  • In patients with a suppressed HPA axis:
    • For mild illness (e.g. UTI, common cold), single dental extraction: double the daily dose (if off steroids, give 40mg hydrocortisone BID)
    • For moderate stress (e.g. flu), minor surgery under local anaesthesia (endoscopy, multiple dental extractions…): give 50mg hydrocortisone BID
    • For major illness (pneumonia, systemic infections, high fever), severe trauma, or emergency surgery under general anaesthesia: give 100mg hydrocortisone IV q 6–8 hrs for 3–4 days until the stress is resolved
  • For elective surgery
    • Steroid stress doses for elective surgery
      • On day of surgery, 50 mg cortisone acetate IM, followed by 200 mg hydrocortisone IV infused over 24 hrs
          • Post-op day
          Hydrocortisone (mg) 8 AM
          Hydrocortisone (mg) 4 PM
          Hydrocortisone (mg) 10 PM
          1
          50
          50
          50
          2
          50
          25
          25
          3
          40
          20
          20
          4
          30
          20
          10
          5
          25
          20
          5
          6
          25
          15
          —
          7
          20
          10
          —