Definition
• Condition in which the adrenal glands, do not produce adequate amounts of steroid hormones, primarily cortisol, but may also include impaired aldosterone production
• Primary adrenal insufficiency (Addison’s dz) refers to pathology of the adrenal cortex, where secondary adrenal insufficiency may occur as a result of pituitary or hypothalamic dzs.
• Dysfxn of the hypothalamic–pituitary–adrenal axis in critical illness is termed critical illness-related corticosteroid insufficiency (CIRCI)
History
• Weakness, fatigue, anorexia, nausea, vomiting, presyncope, craving for salt
• Meds (see Differential table); also elicit if pt is on chronic steroids at baseline
Physical Exam
• Orthostatic hypotension, hyperpigmentation, vitiligo
Evaluation
• Labs: Chem 7 (may see hypoglycemia, hyponatremia, hyperkalemia, acidosis), CBC (may see mild normocytic anemia, lymphocytosis, & eosinophilia); send serum cortisol/ACTH level for inpt w/u
• Serum cortisol >25 μg/dL in a pt requiring intensive care likely rules out adrenal insufficiency
• CIRCI is best diagnosed by a delta cortisol (after 250 μg cosyntropin) of <9 μg/dL or a random total cortisol <10 μg/dL
• ACTH stimulation test is rarely used in the ED
• Imaging: Consider head MR (assess pituitary), adrenal CT
Treatment (Only Start ED Treatment if Symptomatic/Hypotensive)
• Steroids: Hydrocortisone 100 mg IV bolus, followed by continuous infusion at 10 mg/h; may also give 200 mg/d in 4 divided doses
• IV hydration: Volume resuscitation w/ nl saline
• Steroids (particularly, hydrocortisone) should be considered in the management strategy of pts w/ septic shock, particularly those pts who have responded poorly to fluid resuscitation & vasopressors (SBP < 90, despite IVF & vasopressors)
Disposition
• Home: Stable, already on meds
• Admit: All pts w/ new onset adrenal insufficiency; may require ICU admission if concomitant infection or HD unstable
Pearls
• Acute adrenal insufficiency should be suspected in the presence of fluid & pressor-refractory hypotension, esp in a pt w/ signs & sxs as noted above
• Pts w/ known adrenal insufficiency & concomitant febrile illness should be instructed to increase their home dose of steroid by 2–3 times until recovery to prevent possible adrenal crisis. Stress dose steroids can be given in the ED prior to disposition.
Consensus: Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and treatment of corticosteroid insufficiency in critically ill adult patients: Consensus statement from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008;36:1937–1949.