Kenny-Joe Wallen

The University of Kansas

Acute Adrenal Crisis Related to Exogenous

Steroid Use and Surgical Stress

Life is full of Stress

PhysicalMental Emotional NutritionalChemicalTraumaticPyscho-spiritual

General Adaptation Syndrome Stage 1- Alarm

Fight or Flight Response- SNS activation Hormone release and activation- Adrenalin

HPA axis- Cortisol

Stage 2- Resistances PSNS activity returns Glucose, Cortisol, and Adrenalin levels remain elevated in

circulation

Stage 3- Exhaustion If stressor continues beyond body’s capacity, organism

exhausts resources and becomes susceptible to disease and death.

HPA Axis“The Stress Response”

Hypothalamus Corticotropin-releasing hormone

(CRH)

Pituitary Gland Adrenocorticotropic (ACTH)

Adrenal gland Glucocortacoids

Cortisol Mineralocorticoids

Aldosterone

*HPA axis is regulated by a negative feedback mechanism

Adrenal Insufficiency

Primary- Destruction of all cortical zones

TB Autoimmune Congenital Infection

AIDS most common cause Malignancy Trauma

Secondary ACTH deficiency secondary

to Hypothalamic or Pituitary dysfunction

HPA Suppression due to glucocorticoid therapy

**Both forms will require supplemental steroids**

Corticosteroids 1.2% of population > 20 yr

(~2,513,259)/ over 20 years 34 million prescriptions/ year

HPA suppression can occur after five daily doses of prednisone ≥ 20 mg and recovery of HPA function occurs gradually and can take up to 12 months

Adrenal gland atrophy and HPA suppression

Unable to respond to the stress of surgery

Surgery One of the most potent activators of the

HPA axis Endotracheal Intubation Reversal Extubation

Negative feedback mechanism fails ACTH and Cortisol

Cortisol Normal secretion- 20-30 mg/day During stress- as high as 200-500 mg/day

Surgery Patients receiving chronic corticosteroid have atrophy of

their adrenal gland and subsequent suppression of the HPA axis rendering them incapable of producing an adequate amount of endogenous glucocorticoids to meet the demands of the operative stress. These individuals will present with signs and symptoms of adrenal insufficiency

Adrenal Insufficiency

Signs and Symptoms Hypoglycemia Hypotension Tachycardia Tachypnea Anorexia, weight loss Nausea, Vomiting, Abd

pain Hypo NA Hyper K Acidosis Mucosal and Skin

pigmentation Δ Muscle Weakness Fever

Anesthetic Implications Preoperatively

H&P Disease Process Medications How long? Last dose?

Intraoperatively Avoid Etomidate Early recognition of S&S of adrenal crisis

Treatment Rapid IV infusion with saline /c cardiac monitoring Steroid replacement therapy “Stress dosing” If hemodynamically unstable consider inotropic support

Surgical Stress Medical Stress

Glucocorticoid Dosages

Minimal <1° under local anesthesia/ skin

biopsy, routine dental work

Non-febrile cough/ URI

15-30 mg/ day

Minor Hernia repairColonoscopy

Viral IllnessBronchitis

UTI

25 mg IV @Induction(40-60 mg/ day PO in

divided doses)

Moderate Open cholecystectomyTotal joint

replacementAbdominal

hysterectomy

GastroenteritisPneumonia

Pyenephritis

75 mg/ day (25 mg IV q 8°) day of surgery. Taper over next 1-2

days

Severe Cardiothoracic surgeryWhipple

Liver resection

PancreatitisMI

Labor

150 mg/ day (50 mg IV q 8°) day of

surgeryTaper over next 2-3

days

Critical/ Intensive

Care

Major TraumaLife-threatening

complication

Septic Shock Max 300/ day(50 mg IV q 6° or

continuous infusion)

Guidelines for Glucocorticoid Supplementation

References

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Jung, C., & Inder, W. J. (2008). Management of adrenal insufficiency during the stress of medical illness and surgery. Medical Journal of

Australia, 188, 409-413.

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