E27.4
DESCRIPTION
Acute failure of adrenal function, suspected when a patient presents with hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia and metabolic acidosis.
Patients on chronic steroid therapy are at risk for adrenal insufficiency.
Consider augmentation of the steroid dose during times of stress (fever, trauma and surgery).
DIAGNOSTIC CRITERIA
Clinical
- Acute circulatory collapse. The features include:
- tachycardia,
- hypotension,
- pallor,
- poor peripheral perfusion,
- cool clammy skin,
- dehydration,
- coma,
- metabolic acidosis,
- decreased level of consciousness.
- A history of weakness, anorexia, vomiting, weight loss, salt craving, hyperpigmentation (primary adrenal insufficiency),
- Auto-immune endocrinopathies, steroid-dependence and ambiguous genitalia may be present.
- Hyperkalaemia.
- Hypoglycaemia.
- Hyponatraemia.
Investigations
Take blood for estimation of
- Serum electrolytes and blood glucose.
- In all suspected cases, take a sample of clotted blood for estimation of plasma cortisol prior to treating the patient. Send this sample with the patient to the central hospital if laboratory facilities are not locally available.
MEDICINE TREATMENT
Stabilisation
For shock
- Sodium chloride 0.9%, IV, 20 mL/kg bolus as needed.
For hypoglycaemia
Dextrose 10%, IV, 2–5 mL/kg bolus as needed.
- Hydrocortisone, IV, 2 mg/kg immediately as a single dose.
- Follow with 0.5 mg /kg/dose every 6 hours.
Manage hyperkalaemia. See Acute kidney injury (Renal failure, acute) .
Prevention
Patients on chronic steroid therapy are at risk of adrenal insufficiency during stressful situations e.g. sepsis, trauma, elective or emergency surgery. Augment the dose of steroids for the duration of stress.
For major stress:
- Hydrocortisone, IV, 2 mg/kg/day for the duration of the stress.
For minor stress, e.g. URTI:
- Hydrocortisone, IV, 1 mg/kg/day for 3 days.
Adrenal insufficiency is a life threatening emergency
REFERRAL
- All cases immediately after stabilisation.