Adrenal Insufficiency

Question 1

What is the major glucocorticoid released by the adrenal glands?

Answer 1

Hydrocortisone

Question 2

How much cortisol is actually active in the body?

Answer 2

10%

Question 3

What is the mechanism of CIRCI in septic shock?

Answer 3

Suppression of the hypothalamic-pituitary level by inflammatory cytokines

Question 4

Why are total cortisol levels often misleading?

Answer 4

Because the total cortisol levels include the bound cortisol which is 90%, but this could be diminished while the active cortisol level is normal or high.

Question 5

What are the drugs that increase the metabolism of cortisol?

Answer 5

Phenytoin

Rifampin

Question 6

What are the drugs that decrease the synthesis of cortisol?

Answer 6

Ketoconazole

Etomidate

Question 7

What is the principal manifestation of adrenal insufficiency in the ICU.

Answer 7

Hypotension refractory to volume resuscitation

Question 8

How do you diagnose adrenal insufficiency

Answer 8

ACTH stimulation test
Total cortisol level
Random cortisol level

Question 9

What is the best test for diagnosing adrenal insufficiency

Answer 9

Random cortisol level

Question 10

What is a normal ACTH stimulation test?

Answer 10

Less than 9 ug/dl increment after ACTH

Question 11

What is the dose of ACTH to give for the stimulation test?

Answer 11

250 ug/dl

Question 12

What is a normal random plasma cortisol?

Answer 12

Above 35 ug/dl

Question 13

How much cortisol do we produce daily?

Answer 13

15-25 mg/day

Question 14

What level or random cortisol level would suggest adrenal insufficiency?

Answer 14

Less than 10 ug/dl

Question 15

What is the shortcoming of an ACTH stimulation test in diagnosing adrenal insufficiency?

Answer 15

It would not tell you if the hypothalamus was being suppressed

Question 16

What is suggested for patients with septic shock?

Answer 16

A trial of IV hydrocortisone when hypotension is refractory to volume resuscitation

Question 17

What is the treatment of critical illness related adrenal insufficiency

Answer 17

200-300 mg daily of hydrocortisone

(50 mg IV q6h or 100 mg q8h

Question 18

What is the mechanism of adrenal insufficiency in the ICU?

Answer 18

ACTH from the anterior pituitary is blocked from hitting the adrenal gland by inflammatory cytokines

Drugs decrease the production of cortisol (ketoconazole, etomidate)

Infection causing hemorrhage of the adrenal glands

CRF from the hypothalamus is blocked by inflammatory cytokines

Question 19

What is an equivalent prednisone dose to hydrocortisone?

Answer 19

20 mg of hydrocortisone to 5 mg of prednisone

Question 20

What is the hydrocortisone equivalent of methylprednisone

Answer 20

20 mg of hydrocortisone to 4 mg methylprednisone

Question 21

What is the hydrocortisone equivalent to dexamethasone?

Answer 21

20 mg to 0.75mg

Question 22

How does ACTH do?

Answer 22

Stimulates zone glomerulosa of the adrenal cortex to release aldosterone
Stimulates cortisol production in the zona fasciculata

Question 23

What do glucocorticoids do?

Answer 23

Produce more aldosterone

Inhibit phospholipase A2

Question 24

What does phospholipase A2 do?

Answer 24

Creates arachidonic acid from phosphatidylcholine which is the precursor to prostaglandins, leulotrienes and other inflammatory cytokines

Question 25

What is the dosing of stress dose steroids?

Answer 25

200-300 mg/day
50 mg IV q6h
100 mg IV q8h

Question 26

What is the initial IV bolts dose?

Answer 26

100 mg