Adrenal Insufficiency

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Contents 1 More Specific Terms 2 Etiology 3 Laboratory 4 Management 5 More General Terms 6 Additional Terms 7 References

More Specific Terms

• Addison's disease (primary adrenal failure)
• adrenocortical insufficiency without ovarian defect
• congenital adrenal hypoplasia
• secondary adrenal insufficiency (SAI); central adrenal insufficiency
• Waterhouse-Friderichsen syndrome

Etiology

• primary -> adrenal destruction
• secondary -> failure of ACTH secretion Clinical manifestions:

• chronic adrenal insufficiency

• symptoms

• weakness & fatigue (100%)
• anorexia (100%)
• nausea & diarrhea
• muscle, joint & abdominal pain (10%)
• postural dizziness
• salt craving [2]

• signs

• weight loss (100%)
• hyperpigmentation (90%, primary disease)
• orthostatic hypotension (90%)
• adrenal calcification (10%, primary disease)
• vitiligo (5%, primary disease)

Laboratory

• serum glucose: hypoglycemia
• serum sodium: hyponatremia
• cosyntropin stimulation test: low serum cortisol
• 24 hour urinary free cortisol

Management

• administration of glucocorticoids to patients with septic shock or early ARDS should be based on clinical criteria, not on results from ACTH stimulation tests [4]
• consider hydrocortisone for septic shock, especially with poor response fluid resuscitation & vasopressors

• hydrocortisone 200 mg IV daily divided QID, or as bolus of 100 mg followed by continuous infusion at 10 mg/hour (240 mg daily)

• consider glucocorticoids in moderate doses for patients with early severe ARDS ( PaO2/ FiO2 <200) & before day 14 in patients with refractory ARDS

• methylprednisolone 1 mg/kg daily IV continuous infusion

• septic shock & early ARDS:

• dosage unclear
• duration:

• least 7 days before glucocorticoids are tapered (assuming no recurrence of sepsis or shock),
• early ARDS, least 14 days before tapering begins
• taper slowly
• never stop abruptly

• fludrocortisone 50 ug PO QD optional
• dexamethasone not recommended for treatment of septic shock or ARDS.

• Also see Addison's disease ( primary adrenal failure).

More General Terms

• adrenal gland disease

Additional Terms

• adrenal (suprarenal) gland

References

1. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
2. Brender E et al, Adrenal Insufficiency, JAMA 294:2528, 2005
3. Annane D et al, Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006, 174:1319 PMID: [1]
   - Meyer NJ and Hall JB Relative adrenal insufficiency in the ICU: Can we at least make the diagnosis? Am J Respir Crit Care Med 2006, 174:1282 PMID: [2]
4. Marik PE et al, Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: Consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med 2008 Jun; 36:1937 PMID: [3]

adrenal insufficiency