Addisons Disease

Question 1

What are the symptoms of Addison’s disease?

Answer 1

Weakness, anorexia, nausea, vomiting, hyperpigmentation,
chronic hypotension, hypovolemia, hyponatremia, and
hyperkalemia.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 2

What are the two types of adrenal insufficiency?

Answer 2

There are two classifications of adrenal insufficiency: primary
and secondary. In primary adrenal insufficiency the adrenal
glands cannot produce enough hormones. Secondary adrenal
insufficiency is due to suppression or disease of the
hypothalamic/pituitary axis. Addison’s disease is the idiopathic
autoimmune destruction of the adrenal gland and is a form of
primary adrenal insufficiency.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 3

How do the effects of primary adrenal insufficiency

differ from secondary insufficiency?

Answer 3

Primary adrenal insufficiency results in the inadequate release
of glucocorticoid, mineralocorticoid, and androgen hormones.
Secondary adrenal insufficiency results in the inadequate
release of glucocorticoid only.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 4

What are the most common causes of secondary

adrenal insufficiency?

Answer 4

Iatrogenic causes are the most common and include
administration of synthetic glucocorticoids and pituitary surgery
or irradiation.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 5

What patients are at risk for adrenal insufficiency?

Answer 5

Any patient on chronic exogenous steroid therapy is at risk for
adrenal insufficiency during periods of stress such as surgery.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 6

What plasma cortisol level is diagnostic of adrenal

insufficiency?

Answer 6

Plasma levels less than 20 mcg/dL indicate adrenal insufficiency
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398.

Question 7

How does general anesthesia affect activation of the

HPA axis? How does regional anesthesia affect it?

Answer 7

Deep general anesthesia and regional anesthesia both
postpone the increase in plasma cortisol secretion until the
postoperative period.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 8

What are the surgical factors that influence the
activation of the hypothalamic-pituitary-adrenal
axis? How does surgery affect it?

Answer 8

The magnitude and duration of surgery determine the degree to
which the HPA axis is stimulated. Increases in
adrenocorticotropic hormone begin immediately after incision,
remain elevated during surgery, and peak at the time
neuromuscular blockade is reversed. Major surgery can
elevate plasma cortisol secretion from 15 to 25 mg/day to 75 to
150 mg/day.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 9

How long after abrupt withdrawal of steroids would
symptoms begin to appear in a patient on a longterm
exogenous steroid regimen?

Answer 9

Symptoms would begin to appear within 24 to 36 hours.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.

Question 10

How long after discontinuation of long-term steroid
use will it take for adrenal function to return to
normal?

Answer 10

It can take 6 to 12 months for adrenal function to return to
baseline after chronic exogenous corticosteroid use.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 398-400.