Endo - Adrenal Insufficiency

Question 1

Classify the causes of adrenal insufficiency

Answer 1

Primar, Secondary, Tertiary

Primary - Failure of adrenal - low cortisol
Secondary - Failure of pituitary - low ACTH
Tertiary - Either - failure of hypothalamus (low CRH) OR - chornic steroid use

Question 2

Causes of primary adrenal insuffiency

Answer 2

Auto-immune - Addisons
Infection - TB (adrenal infiltrate), funal infection (histoplasmosis) HIV causing CMV infection and adrenalitits
Cancer - Mets or primary
Drugs - etomidate, ketoconazole
Other - Critical illness insufficiency (relative)
Adrenalectomy
Irradiation
Iron deposit - haemochromatosis

Question 3

Causes of secondary/tertiary

Answer 3

Chronic steroid use suppresing the axis
Malignancy brain
Haemorrhage
Infarct (sheehans)

Question 4

How to diagnose adrenal insufficiency

Answer 4

Cortisol and ACTH

Primary - low cortisol high ACTH
Secondary - both low
Beware exogenous steroids
Standard test - Synacthen test
Cortisol by measured beofre and after ACTH Failure to rise after 30 minutes - adrenal insufficency
Negative - rules out primary BUT NOT secondary
Adrenal antibodies and radiology

Question 5

What is addisons

Answer 5

Adrenal cortex fails due to autoimmune disease.Reduced or absent cortisol levels

Causes - autoimmune, irradiation, surgery
Often with mineralocorticoid deficiency

Question 6

Why pigmentation in addisons

Answer 6

No coritsol means high ACTH
ACTH has a precurso molecule (pro-opiomelanocortin) which makes melanocyte stimulating hormone
Increases –> pigments

Question 7

Describe the Addisonian crisis

Answer 7

Systems:
CVS: High output distributive shock (low BP, tachy, vasoplegua
Neuro: Lethargy, fatigue, weakness, headache, dizzy, confusion, LOC
GI - D&V, abdo pain
Skin - pigmentation
Ix - Low Na, High K, metabolic acidosis
Low sugars

Question 8

Biochemical abnormalities in addison crisisWhat other diseases may present with is

Answer 8

Ix - Low Na, High K, metabolic acidosisLow sugars
Pernicious anaemia
Graves (autoimmune)

Question 9

Management

Answer 9

ABCDE
High output shock that needs vasopressors
Differential is sepsis
Focus - correct BP, electrolyte issues and replace cortisol

Resus
Large bore iv access
FBC, U&E, Glucose, Cortisol, ACTH
Fluid resus
BM and correct
Replace steroids
200mg iv hydrocrot followed by 100mg 6 hourly
Mineralocorticoids not needed acutely
Consider fludrocortison with endocrine
Invasive monitoring and level2-3 care
Find that cause!
Sepsis/SurgerySteroid use
Autoimmune disease
Infectious disease
Drugs
Cancer
Pregancy

Question 10

What is relaitve hypoadrenalism

Answer 10

Common in critical illness
Describes the relative and absoltue failure of cortisol
Surviving sepsis - you can give steroids in vasopressor resistant shock (low evidence)
But do not stratify by measurements of cortisol

Question 11

List five reasons for corticosteroid use in the critical care setting.

Answer 11

Airway— croup or post-op ENT/maxillofacial surgery.

Breathing:
- anaphylaxis;
- pneumonia;
- chronic obstructive pulmonary disease (COPD);
- Pneumocystis jirovecii.

Circulation:
- vasopressor refractive shock, for example, in septic shock.

Endocrine:
- Addison’s disease;
- hypercalcaemia;
- Addisonian crisis — in patients who have been on long-term steroid use.

Nervous system:
- myasthenic crisis;
- myxoedema coma;
- brain tumour swelling;
- bacterial meningitis.

Organ donation— post brainstem death testing.

Malignancy

Question 12

What is the role of the short synacthen test and steroids in severe sepsis or septic shock?

Answer 12

-The test is not recommended as routine practice in severe sepsis or septic
shock (Surviving Sepsis Guidelines,
* Due to a variation in the free cortisol fraction the adrenal function cannot be
accurately assessed in sepsis.
* The Surviving Sepsis Guidelines have made a recommendation that
corticosteroids (CCS) can be used in vasopressor refractive shock.