Adrenocortical Insufficiency (Addisonian crisis) 

 

 

Background

 

  • Primary Addisonian crisis commonly due to autoimmune destruction of adrenal gland; mineralocorticoid activity also lost

  • Secondary Addisonian crisis caused by ↓ ACTH production either from hypothalamic pituitary disease or from adrenal suppression from chronic steroids, mineralocorticoid activity usually preserved

 

 

Considerations

 

  • Potential life-threatening situation: shock, dehydration, hypotension

  • Physiologic abnormalities:

    • Cardiovascular:

      • Impaired myocardial contractility

      • Arrhythmias secondary to hyperkalemia

    • Volume status: dehydration can occur (2-3 L)

    • Electrolyte imbalance

      • Hyperkalemia

      • Hyponatremia (↓ level of consciousness, seizures)

      • Hypoglycemia (↓ level of consciousness, seizures) 

  • Stress dosing of steroids pre-operatively:

    • Hydrocortisone 100mg IV q6-8h

    • Fludrocortisone if 1° adrenal insufficiency 

  • Pharmacologic concerns:

    • ↓ circulating catecholamines (consider vasopressin for hypotension)

    • Succinylcholine-induced hyperkalemia 

 

 

Goals

 

  • Prevent perioperative cardiovascular collapse:

    • Steroid supplementation

    • Volume resuscitation

    • Correction of electrolyte abnormalities 

 

 

Medications

 

  • Hydrocortisone 100mg IV q6-8h for 24h then taper to maintenance of 15-20mg PO qAM & 5-10mg PO qPM

  • Add maintenance fludrocortisone 0.05-0.2mg PO daily if aldosterone-deficient (1° adrenal insufficiency) when tapering hydrocortisone  

 

 

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