And It's About Time There Was Some Support For Cushing's!
Adrenal Crisis excerpt Synonyms and related keywords: acute adrenal crisis, acute adrenocortical insufficiency, acute adrenal insufficiency, addisonian crisis, adrenal apoplexy, cortisol, aldosterone, primary adrenocortical insufficiency, secondary adrenocortical insufficiency, bilateral massive adrenal hemorrhage, BMAH
| WORKUP | Section 5 of 10 | ||
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Histologic Findings: Histology depends on the cause of the adrenal failure. In primary adrenocortical failure, histological evidence of infection, infiltrative disease, or other condition may be demonstrated. Secondary adrenocortical insufficiency may cause atrophy of the adrenals or no histologic evidence at all, especially if due to exogenous steroid ingestion. Appearance of bilateral adrenal hemorrhage may be striking, as if bags of blood are replacing the glands.
| TREATMENT | Section 6 of 10 | ||
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| MEDICATION | Section 7 of 10 < | ||
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Corticosteroids are the mainstays of treatment. Other medications, such as pressors (eg, dopamine, norepinephrine) or antibiotics, are administered as clinically indicated.
Drug Category: Corticosteroids -- These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
| Drug Name | Dexamethasone (Decadron, Baldex, Dexone) -- Used as empiric treatment of shock in suspected adrenal crisis or insufficiency until serum cortisol levels are drawn. |
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| Adult Dose | 4-8 mg IV, followed by 16-24 mg/d as IV injection q4-6h or as continuous infusion |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; active bacterial or fungal infection |
| Interactions | Effects decrease with coadministration of barbiturates, phenytoin, and rifampin |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use; may prolong coma in cerebral malaria |
| Drug Name | Hydrocortisone (Hydrocortone, Hydrocort) -- DOC because of mineralocorticoid activity and glucocorticoid effects. |
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| Adult Dose | 100 mg IV q6h for 24 h; if stabilized, reduce to 50 mg IV q6h for 4 doses, then 25 mg IV q6h for 4 doses, then change to PO dose of cortisone acetate or cortisol |
| Pediatric Dose | <12 years: 1-2 mg/kg IV bolus;
follow with 25-150 mg/d divided q6-8h >12 years: 1-2 mg/kg IV bolus; follow with 150-250 mg/d divided q6-8h |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin infections |
| Interactions | Corticosteroid clearance may decrease with estrogens |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis |
| Drug Name | Cortisone acetate (Cortone) -- Oral DOC for patients with adrenocortical insufficiency. |
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| Adult Dose | 37.5 mg PO q12h for 2 d; 25 mg PO every am and 12.5 mg PO every pm until stabilized |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin lesions |
| Interactions | Estrogen coadministration may increase corticosteroid levels; cortisone may increase digitalis toxicity secondary to hypokalemia; phenytoin, phenobarbital, rifampin, and ephedrine increase corticosteroid clearance; may inhibit response to coumarin anticoagulants; exacerbation of hypokalemia with potassium-depleting diuretics may occur |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, osteoporosis, peptic ulcer, diabetes, and myasthenia gravis; may exacerbate existing emotional instability; may mask signs of GI peritonitis and sepsis; may impair growth and development in children; caution in peptic ulcer disease; caution in infections |
| Drug Name | Fludrocortisone (Florinef) -- Acts on renal distal tubules to enhance reabsorption of sodium. Increases urinary excretion of both potassium and hydrogen ions. The consequence of these 3 primary effects, together with similar actions on cation transport in other tissues, appears to account for the spectrum of physiological activities characteristic of mineralocorticoids. Used in stable adrenal insufficiency. Produces marked sodium retention and increased urinary potassium excretion. |
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| Adult Dose | 0.1-0.2 mg PO qd |
| Pediatric Dose | 0.05-0.1 mg PO qd |
| Contraindications | Documented hypersensitivity; systemic fungal infections |
| Interactions | Antagonizes effects of anticholinergics; rifampin, hydantoins, and barbiturates decrease effects of fludrocortisone; decreases salicylate levels |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Taper dose gradually when therapy is discontinued; caution in Addison disease, potassium loss, and sodium retention |
Drug Category: Vasopressors-- Decrease portal circulation pressure by diminishing blood flow due to vasoconstriction. Major indication in variceal bleeding.
| Drug Name | Norepinephrine (Levophed) -- For protracted hypotension following adequate fluid-volume replacement. Stimulates beta1 alpha-adrenergic receptors, which, in turn, increases cardiac muscle contractility and heart rate, as well as vasoconstriction. As a result, systemic blood pressure and coronary blood flow increases. After obtaining a response, the rate of flow should be adjusted and maintained at a low-normal blood pressure, such as 80-100 mm Hg systolic, sufficient to perfuse vital organs. |
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| Adult Dose | 4-12 mcg/min IV infusion; titrate to desired perfusion status |
| Pediatric Dose | 0.1 mcg/kg/min IV; titrate to desired perfusion status |
| Contraindications | Documented hypersensitivity; peripheral or mesenteric vascular thrombosis because ischemia may be increased and the area of the infarct extended |
| Interactions | Enhances pressor response of norepinephrine by blocking reflex bradycardia; MAOIs, TCAs, antihistamines, guanethidine, ergot alkaloids, and methyldopa increase effects |
| Pregnancy | D - Unsafe in pregnancy |
| Precautions | Correct blood volume depletion, if possible, before administering norepinephrine therapy; extravasation may cause severe tissue necrosis and, thus, should be administered into a large vein; caution in occlusive vascular disease; extravasation can cause tissue necrosis |
| Drug Name | Dopamine (Intropin) -- Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effect is dependent on the dose. |
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| Adult Dose | 0.5-20 mcg/kg/min IV infusion; titrate to desired perfusion status |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; pheochromocytoma; ventricular fibrillation |
| Interactions | Phenytoin, alpha- and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong effects of dopamine |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Monitor urine flow, cardiac output, pulmonary wedge pressure, and blood pressure closely during the infusion; prior to infusion, correct hypovolemia with either whole blood or plasma because pressure may be helpful in detecting and treating hypovolemia; extravasation can cause tissue necrosis |
| FOLLOW-UP | Section 8 of 10 | ||
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| MISCELLANEOUS | Section 9 of 10 | ||
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Perioperative Steroid Therapy for Patients with Known Adrenal Insufficiency
| Timing | Hydrocortisone | Hydrocortisone | Fludrocortisone |
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| Routine daily | … | 20 mg PO at 8 am 10 mg PO at 4 pm |
0.1 mg PO at 8 am |
| Day of operation | 10 mg/h continuous infusion | … | … |
| Postoperative day 1 | 5-7.5 mg/h continuous infusion | … | … |
| Postoperative day 2 | 2.5-5 mg/h continuous infusion | … | … |
| Postoperative day 3 | 2.5-5 mg/h continuous infusion or | 40 mg PO at 8 am 20 mg PO at 4 pm |
0.1 mg PO at 8 am |
| Postoperative day 4 | 2.5-5 mg/h continuous infusion or | 40 mg PO at 8 am 20 mg PO at 4 pm |
0.1 mg PO at 8 am |
| Postoperative day 5 | … | 40 mg PO at 8 am 20 mg PO at 4 pm |
0.1 mg PO at 8 am |
| Postoperative day 6 | … | 20 mg PO at 8 am 20 mg PO at 4 pm |
0.1 mg PO at 8 am |
| Postoperative day 7 | … | 20 mg PO at 8 am 10 mg PO at 4 pm |
0.1 mg PO at 8 am |
| BIBLIOGRAPHY |
Section 10 of
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| NOTE: |
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| Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER |
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