Adrenocortical Insufficiency (Addisonian crisis)
Background
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Primary Addisonian crisis commonly due to autoimmune destruction of adrenal gland; mineralocorticoid activity also lost
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Secondary Addisonian crisis caused by ↓ ACTH production either from hypothalamic pituitary disease or from adrenal suppression from chronic steroids, mineralocorticoid activity usually preserved
Considerations
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Potential life-threatening situation: shock, dehydration, hypotension
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Physiologic abnormalities:
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Cardiovascular:
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Impaired myocardial contractility
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Arrhythmias secondary to hyperkalemia
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Volume status: dehydration can occur (2-3 L)
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Electrolyte imbalance
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Hyperkalemia
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Hyponatremia (↓ level of consciousness, seizures)
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Hypoglycemia (↓ level of consciousness, seizures)
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Stress dosing of steroids pre-operatively:
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Hydrocortisone 100mg IV q6-8h
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Fludrocortisone if 1° adrenal insufficiency
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Pharmacologic concerns:
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↓ circulating catecholamines (consider vasopressin for hypotension)
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Succinylcholine-induced hyperkalemia
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Goals
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Prevent perioperative cardiovascular collapse:
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Steroid supplementation
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Volume resuscitation
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Correction of electrolyte abnormalities
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Medications
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Hydrocortisone 100mg IV q6-8h for 24h then taper to maintenance of 15-20mg PO qAM & 5-10mg PO qPM
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Add maintenance fludrocortisone 0.05-0.2mg PO daily if aldosterone-deficient (1° adrenal insufficiency) when tapering hydrocortisone