Adrenal Crisis

Question 1

What can cause adrenal crisis?

Answer 1

Stopping steroids in patients with adrenal insufficiency, or if dose isn’t adjusting during physiological stress (illness or surgery)

Question 2

Name 3 reasons for primary AI

Answer 2

1. Addisons disease
2. Congenital adrenal hyperplasia
3. Bilateral adrenalectomy
4. Bilateral adrenal haemorrhage
5. Bilateral adrenal metastasis

Question 3

Name 3 reasons for secondary/tertiary AI

Answer 3

1. Pituitary disease
2. Hypothalamo-pituitary damage from tumours or surgery
3. Drug induced
4. Exogenous steroids

Risk increased during illness, surgery, childbirth, or interruption in glucocorticoid replacement therapy

Question 4

What dose of hydrocortisone/prednisone is given to manage moderate illness in at risk patients

Answer 4

Hydrocortisone 20mg stat, followed by 10mg every 6 hrs (or prednisone 5mg bd)

Question 5

How do you prevent adrenal crisis in peri operative period

Answer 5

Give extra glucocorticoid, never miss or delay doses , resume double regular dose for 2-7 days

Question 6

Name 5 symptoms of adrenal crisis

Answer 6

1. Fatigue/malaise/weight loss
2. Low bp, dizziness, postural hypotension, collapse, hypovolaemic shock
3. Abdo pain, tenderness, k&c
4. Fever
5. Confusion
6. Back/leg cramps/ spasams
7. Low Na+ hypoglycaemia

Question 7

What investigations need to be quickly done before managing AI?

Answer 7

1 drug history to establish pre-admission dose across all routes or recent courses
2 BP laying and standing
3 bloods - FBC, U&Es, glucose, cortisol

Question 8

How do you manage adrenal crisis?

Answer 8

IV hydrocortisone, fluids or resuscitate with saline until haemodynamically stable
Monitoring - bloods, cardiac monitoring
Referral to endocrine

Question 9

What patients are at risk of adrenal crisis with systemic steroids?

Answer 9

Long term - 4wks
Short term - 1wk
Repeated anti emetic dexamethasone for anti cancer
Prolonged course oral/IV dexamethasone (10d) for covid