Adrenal insufficiency

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  1. Adrenal cortex releases glucocorticoids and mineralocorticoids that promote glucose availability and maintain extracellular volume
  2. Adrenal medulla releases catecholamines that support the circulation
  3. Loss of adrenal function leads to hemodynamic instability, volume depletion and defective energy metabolism
  4. Adrenal insufficiency may remain silent until times of stress, especially in critically ill patients in whom free cortisol level remains normal while total cortisol level is reduced
  5. Predisposing conditions
    1. major surgery
    2. circulatory failure
    3. septic shock
    4. severe coagulopathy
    5. human immunodeficiency virus (HIV) infection
  6. Most prominent manifestation of adrenal insufficiency is hypotension that will not respond to vasopressors
    1. also see hyponatremia, hyperkalemia, weakness and hyperpigmentation
    2. physiologic state similar to septic shock ( hyperdynamic shock, with increased cardiac output and low systemic vascular resistance)
  7. Diagnosis
    1. ACTH stimulation test (a baseline cortisol level <15 mcg/dl, unchanged or followed by and increase of < 9 mcg/dl, within 60 minutes after 250 mcg of ACTH is injected intravenously, is considered diagnostic for adrenal insufficiency)
  8. Therapy
    1. steroids – Decadron 2 mg IV right away ( if severe or refractory hypotension is present) then hydrocortisone (Solu-Cortef) 50 mg q6h, until the ACTH test results are avialble. If the ACTH test is negative, Solu-Cortef can be discontinued abruptly; if the ACTH test is positive, Solu- Cortef is administered as needed, then tapered down to 20 mg daily before discontinuation.
      1. NOTE: Decadron .75 mg (dexamethasone) has least mineralocorticoid effect and most glucocorticoid effect, Prednisone and solumedrol (prednisolone) 5 mg have slightly more glucocorticoid effect than mineralocorticoid effect, Solucortef (hydrocortisone) 20 mg has equal glucocorticoid and mineralocorticoid effect, Florinef (fludrocortisone) .05 mg has no glucocorticoid effect and most mineralocorticoid effect
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