Adrenal Insufficiency

Question 1

Definition

Answer 1

Also known as ‘Addison’s disease

a disorder that occurs when the adrenal glands does not make enough hormones, specifically cortisol.

Question 2

How is cortisol released?

Answer 2

The hypothalamus releases CRH (corticotropin releasing hormone)

This stimulates the pituitary gland to release ACTH (adrenocorticotropic hormone)

ACTH causes the adrenal gland to release cortisol

Question 3

Types of Adrenal insufficiency

Answer 3

Primary
- It occurs when the adrenal glands are damaged, and they do not make enough of the hormone cortisol and aldosterone. This condition is rare, and it may occur at any age.

Secondary
- This is common where the pituitary gland does not produce enough adrenocorticotropic hormone (ACTH). As a result the adrenal cortex does not produce adequate cortisol. The production of aldosterone is normal in this type of adrenal insufficiency

Tertiary
- Referred to impaired hypothermic release of corticotropin-releasing hormone (CRH) which decrease the production of adrenocorticotropic hormone (ACTH)

Question 4

Implications of care

Answer 4

Fluids 
Nutritional intake 
Environment 
Patient education 
Alternative therapies 
Emotional support

Question 5

Etiology

Answer 5

PRIMARY
- Autoimmune response which occurs when the body’s immune system attack its own organs and tissues. This can attack the adrenal cortex, resulting in damage.

• Adrenalectomy: Treatment for cushing’s and patient must take post-operative glucocorticoid medications to supplement cortisol

SECONDARY & TERTIARY
- Pituitary gland or hypothalamus damage from traumatic head or brain injuries so it can not produce ACTH nor CRH

Question 6

Clinical Manifestations

Answer 6

5 S’s & 3 H’s

Super low BP (nothing will bring it up) 
Sudden pain in stomach, back or legs
Syncope (temporary loss of consciousness caused by a fall in blood pressure.)
Shock 
Severe vomiting, diarrhea and headache 

Hyponatremia < 135
Hypoglycemia < 70
Hyperkalemia > 5.1

Question 7

Management

Answer 7

• Priority: Administer cortisol stat via IV line
• IV fluids to replenish: Sodium & glucose (D5W w/ NS)

• Start on oral glucocorticoids 
   - Cortisol = Prednisone 
Educate: increase dose if pt. has increased stress, don’t stop taking abruptly 
  - Aldosterone: Florinef 
 Educate consuming Na+ 

• Monitor labs: glucose, K+, Na+ + prevent infection

Question 8

Diagnostic measures

Answer 8

Antibody test: investigate insufficiency of the adrenal gland and also assess the risk of a person developing autoimmune adrenal insufficiency

ACTH stimulation test: used to diagnose adrenal insufficiency
• Intravenous (IV) injection with ACTH
• Sample of blood is taken
• Reading of cortisol levels

Insulin tolerance test 
• sample of blood is taken
• Insulin is administered
•Time duration of test
• Measure cortisol levels

CRH stimulation test

CT scan

MRI

Question 9

Cortisol

Answer 9

“stress hormone” that helps body deal w/ stress (illness, trauma). It raises blood glucose, breaks down fats, proteins and carbs whilst also playing a role in electrolyte balance

Question 10

Adrenal cortex

Answer 10

produces cortisol

Question 11

Pituitary gland

Answer 11

regulates cortisol by producing ACTH

Question 12

Complications

Answer 12

If it is left untreated for too long, it can become an Addisonian crisis, and the associated symptoms are:

• agitation
• delirium
• visual and auditory hallucinations

An Addisonian crisis is a life-threatening medical emergency which patients may start to experience:

• mental status changes, such as confusion, fear, or restlessness
• loss of consciousness
• high fever
• sudden pain in the lower back, belly, or legs

If Addisonian crisis is left untreated it can lead to shock and even death.