Steroid Cover

Question 1

Where are endogenous steroids (eg cortisol) produced?

Answer 1

Adrenal cortex

Question 2

What are the classifications of adrenal insufficiency?

Answer 2

Primary adrenal insufficiency
Secondary adrenal insufficiency

Question 3

Primary adrenal insufficiency is also known as ___________ disease

Answer 3

Addison’s

Question 4

What is the most common cause (80%) of primary adrenal insufficiency?

Answer 4

Autoimmune destruction of the adrenal gland / autoimmune adrenalitis

Question 5

Apart from autoimmune destruction of the adrenal gland, what are the other possible causes of adrenal gland destruction?

Answer 5

Tuberculosis
Malignancy
Iatrogenic (eg surgical removal of kidney)

Question 6

Destruction of adrenal gland leads to decreased __________ and _______-__________ levels.

Answer 6

Mineralo, gluco-corticoid

Question 7

What is primary adrenal insufficiency characterised by? (2 points)

Answer 7

Mineralocorticoid deficiency
Hyperpigmentation

Question 8

Where can hyperpigmentation develop in Addison’s patients?

Answer 8

Buccal mucosa
Palmar creases of the hands

Question 9

What is ACTH, to some extent, analogous to? (which explains about the hyperpigmentation when there is an increased production in ACTH)

Answer 9

Melanocyte stimulating hormone

Question 10

What are the signs and symptoms of Addison’s? (7 points)

Answer 10

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

Question 11

What might investigations reveal in patients with Addison’s disease?

Answer 11

Elevated plasma ACTH
Low serum sodium
Raised serum potassium
Adreno-cortical antibodies - often present in autoimmune adrenalitis

Question 12

What might patients who have hypothalamic-pituitary-adrenal (HPA) axis suppression need to take?

Answer 12

Steroid cover or steroid supplementation

Question 13

Why do patients with HPA suppression need steroid cover?

Answer 13

To make up for the deficit of the ability to produce endogenous steroids

Question 14

______ _______ _____ / _______ ________ is when the physiological need for hormones exceeds the ability of adrenal glands to produce them

Answer 14

Acute adrenal crisis / Addisonian Crisis

Question 15

What may cause chronic adrenal insufficiency in patients? (What may cause patients to have a lessened ability to produce endogenous steroids?)

Answer 15

Intercurrent illness or stress

Question 16

What constitutes physiological stress?

Answer 16

Major or minor infections
Injury
Surgery
General anaesthesia

Question 17

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.

Answer 17

Hypotension
Abdominal
Seizures

Question 18

For minor dental procedures under LA on patients with primary adrenal insufficiency, is steroid cover needed?

Answer 18

No

Question 19

For major dental procedures under LA eg difficult surgical extractions on patients with primary adrenal insufficiency, is steroid cover needed?

Answer 19

Yes. Double dose up to and stay at that dose for 24 hours, thereafter returning to normal dose.

Question 20

What type of dental procedures generally require steroid cover?

Answer 20

GA

Question 21

How much steroid cover is generally given to patients with primary adrenal insufficiency who are about to undergo dental procedures under GA?

Answer 21

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

Question 22

What are the advantages and disadvantages of giving steroid covers through the IM route?

Answer 22

CONS: Gets into bloodstream slower (takes ~1 hour) compared to IV (immediate)
PROS: Lasts longer / takes longer to decrease

Question 23

When might steroid covers be needed generally?

Answer 23

In physiologically stressful situations when patients might not be able to produce enough of their own endogenous steroid

Question 24

For patients with significant dental abscess, will they require steroid supplimentation?

Answer 24

Maybe. Liase with physicians.

Question 25

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?

Answer 25

True

Question 26

Emergency treatment of acute adrenal crisis:

Answer 26

1. Lay patient flat
2. Call for help (2222 in hospital; 999 in dental practice)
3. ABCDE approach

When paramedics arrive:
- administration of 200mg hydrocortisone - or approx 4mg/kg for child (IV stat)
- fluid and electrolyte replacement