Steroid Cover Flashcards
Where are endogenous steroids (eg cortisol) produced?
Adrenal cortex
What are the classifications of adrenal insufficiency?
Primary adrenal insufficiency
Secondary adrenal insufficiency
Primary adrenal insufficiency is also known as ___________ disease
Addison’s
What is the most common cause (80%) of primary adrenal insufficiency?
Autoimmune destruction of the adrenal gland / autoimmune adrenalitis
Apart from autoimmune destruction of the adrenal gland, what are the other possible causes of adrenal gland destruction?
Tuberculosis
Malignancy
Iatrogenic (eg surgical removal of kidney)
Destruction of adrenal gland leads to decreased __________ and _______-__________ levels.
Mineralo, gluco-corticoid
What is primary adrenal insufficiency characterised by? (2 points)
Mineralocorticoid deficiency
Hyperpigmentation
Where can hyperpigmentation develop in Addison’s patients?
Buccal mucosa
Palmar creases of the hands
What is ACTH, to some extent, analogous to? (which explains about the hyperpigmentation when there is an increased production in ACTH)
Melanocyte stimulating hormone
What are the signs and symptoms of Addison’s? (7 points)
Always tired
Dizzy when standing (drop in blood pressure)
Inexplicable weight loss
Skin colour changes
Only eating sparingly/anorexia
No strength in handgrip or limbs
Sick or nauseous
What might investigations reveal in patients with Addison’s disease?
Elevated plasma ACTH
Low serum sodium
Raised serum potassium
Adreno-cortical antibodies - often present in autoimmune adrenalitis
What might patients who have hypothalamic-pituitary-adrenal (HPA) axis suppression need to take?
Steroid cover or steroid supplementation
Why do patients with HPA suppression need steroid cover?
To make up for the deficit of the ability to produce endogenous steroids
______ _______ _____ / _______ ________ is when the physiological need for hormones exceeds the ability of adrenal glands to produce them
Acute adrenal crisis / Addisonian Crisis
What may cause chronic adrenal insufficiency in patients? (What may cause patients to have a lessened ability to produce endogenous steroids?)
Intercurrent illness or stress
What constitutes physiological stress?
Major or minor infections
Injury
Surgery
General anaesthesia
ACUTE ADRENAL CRISIS:
Patient is acutely ill with _________, especially postural. They may also be very weak and confused. Feeble rapid pulse.
Anorexia, nausea, vomitting and severe ____________ pain.
Increased motor activity - progressing to ________ if left untreated.
Hypotension
Abdominal
Seizures
For minor dental procedures under LA on patients with primary adrenal insufficiency, is steroid cover needed?
No
For major dental procedures under LA eg difficult surgical extractions on patients with primary adrenal insufficiency, is steroid cover needed?
Yes. Double dose up to and stay at that dose for 24 hours, thereafter returning to normal dose.
What type of dental procedures generally require steroid cover?
GA
How much steroid cover is generally given to patients with primary adrenal insufficiency who are about to undergo dental procedures under GA?
Typically IM or IV hydrocortisone 100-200mg 1 hour prior to surgery or 100-200mg IV at induction and stay at double dose for 24 hours
What are the advantages and disadvantages of giving steroid covers through the IM route?
CONS: Gets into bloodstream slower (takes ~1 hour) compared to IV (immediate)
PROS: Lasts longer / takes longer to decrease
When might steroid covers be needed generally?
In physiologically stressful situations when patients might not be able to produce enough of their own endogenous steroid
For patients with significant dental abscess, will they require steroid supplimentation?
Maybe. Liase with physicians.
When in doubt, it is best to cover patients because it is better to have more steroids circulating around in the bloodstream rather than an inadequate amount. True or false?
True
Emergency treatment of acute adrenal crisis:
- Lay patient flat
- Call for help (2222 in hospital; 999 in dental practice)
- ABCDE approach
When paramedics arrive:
- administration of 200mg hydrocortisone - or approx 4mg/kg for child (IV stat)
- fluid and electrolyte replacement
