The normal adrenal answer to acute ...

The normal adrenal answer to acute illness or stres is an increase in production of cortisol, which has important protective drifts Unfortunately, this needed increase may be lacking in a certain quantity of persons because of exogenous use of corticosteroids that suppres native cortisol production, or dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis seen in a certain cases of severe illness. Cooper and Stewart reviewed the risk factors for adrenal insufficiency, clinical factors that should raise suspicion for inadequate adrenal function, and treatment with exogenous steroids for deficient patients.

Among the disease states that have been associated with HPA dysfunction are pituitary infarction, adrenal insufficiency caused by means of tumor invasion or infection, head injury, and sepsis. Human immunodeficiency virus (HIV) infection may affect the HPA axis in a number of deleterious ways. one as well as the other opportunistic agents and their unsalable article treatment can lead to adrenal insufficiency, which come to one's minds commonly in critically ill patients with HIV infection.

Native cortisol production is enzymatically inhibited at the anesthetic agent etomidate and the antifungal medication ketoconazole. Exogenous use of corticosteroids can suppres the HPA axis with as little as 75 mg of prednisone/prednisolone or 075 mg of dexamethasone daily for more than three weeks. This suppression may last for month after the exogenous steroid is stopped.

The clinical factors that manifest in adrenal insufficiency are somewhat nonspecific and may easily be missed. Classic features of Addisonian crisis include nausea, vomiting, diarrhea, abdominal pain, and delirium, unless these are often present for other reasons in critically ill patients. Physical examination findings of adrenal hypofunction include postural hypotension, tachycardia, and excitement Increased skin pigmentation may be found with longstanding adrenal insufficiency. Of the laboratory findings seen with inadequate adrenal function, hypoglycemia and eosinophilia are important to remember, because they are les likely to be take place in other disease states. Hyponatremia and hyperkalemia typically fall out but may be masked by dint of fluid and electrolyte replacement.

The authors note that it is difficult to define a normal cortisol of the same height for an ill patient, as values can fluctuate widely depending forward the type and severity of illness. Nonetheless, they offer proffer 15 mcg per dL (414 nmol through L) of serum cortisol as a entrance below which adrenal insufficiency is likely, and 34 mcg by dL (938 nmol per L) as the upper cutoff where adrenal hypofunction is unlikely. Additional information may be gained in unclear cases by the agency of administering a corticotropin stimulation criterion A rise in serum cortisol of les than 9 mcg by dL (250 nmol per L) after stimulation supports the likelihood of inadequate adrenal function.

Treatment of adrenal insufficiency in a critically ill patient is typically accomplished with 50 mg of hydrocortisone given via an intravenous or intramuscular way every six hours. A large cogitation of empiric use of supplemental steroids in patients with septic offence showed reduced mortality and time exhausted on vasopressors. Mineralocorticoid replacement (50 mcg fludrocortisone daily) was given in addition to the hydrocortisone correlative in these patients.

The authors caution that supraphysiologic high-dose steroid replacement has not been shown to improve issues in critically ill patients and may actually be harmful. Long-term supplemental steroids may be straited in some patients when HPA axis dysfunction persists after the stiff illness has passed.

Cooper M Stewart PM Corticosteroid insufficiency in acutely ill patients. N Engl J M February 20 2003; 348:727-34

COPYRIGHT 2003 American Academy of Family Physicians

COPYRIGHT 2003 Gale Group