Adrenal Insufficiency in Neurocritically Ill Patients

2019 ◽  
pp. 246-250
Author(s):  
Carla P. Venegas-Borsellino ◽  
Santiago Naranjo-Sierra
Keyword(s):  
Adrenal Insufficiency ◽  
Acute Illness ◽  
Major Surgery ◽  
Blood Levels ◽  
Response To Stress ◽  
Hpa Response ◽  
Critical Care Patients ◽  
Corticosteroid Secretion ◽  
Functional Deficiency ◽  
Corticosteroid Insufficiency

The hypothalamic-pituitary-adrenal (HPA) axis is a complex system that equilibrates blood levels of glucocorticoid hormones. Cortisol levels are dynamic and normally fluctuate in response to constant feedback; functional deficiency in this system results in adrenal insufficiency (AI). An elevated corticosteroid level is needed as a protective response to stress during acute illness or major surgery, but corticosteroid secretion can be altered by splanchnic and central nervous system influence, fever, acidosis, and proinflammatory cytokines. Critical illness–related corticosteroid insufficiency (CIRCI) is a relatively insufficient HPA response; often encountered in critical care patients, it can worsen outcomes.

Acute illness in children with secondary adrenal insufficiency

2021 ◽  
Author(s):  
Rosemary Louise Rushworth ◽  
Nikki Gouvoussis ◽  
Thomas Goubar ◽  
Ann Maguire ◽  
Craig F. Munns ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Acute Illness ◽  
Secondary Adrenal Insufficiency

scholarly journals EXTENSIVE EXPERTISE IN ENDOCRINOLOGY: Adrenal crisis

2015 ◽  
Vol 172 (3) ◽  
pp. R115-R124 ◽  
Author(s):  
Bruno Allolio
Keyword(s):  
Patient Education ◽  
Adrenal Insufficiency ◽  
Well Being ◽  
Stressful Events ◽  
Major Surgery ◽  
Adrenal Crisis ◽  
Self Administration ◽  
Necrosis Factor Alpha ◽  
Hydrocortisone Administration ◽  
Glucocorticoid Deficiency

Adrenal crisis is a life-threatening emergency contributing to the excess mortality of patients with adrenal insufficiency. Studies in patients on chronic replacement therapy for adrenal insufficiency have revealed an incidence of 5–10 adrenal crises/100 patient years and suggested a mortality rate from adrenal crisis of 0.5/100 patient years. Patients with adrenal crisis typically present with profoundly impaired well-being, hypotension, nausea and vomiting, and fever responding well to parenteral hydrocortisone administration. Infections are the major precipitating causes of adrenal crisis. Lack of increased cortisol concentrations during infection enhances pro-inflammatory cytokine release and sensitivity to the toxic effects of these cytokines (e.g. tumour necrosis factor alpha). Furthermore, pro-inflammatory cytokines may impair glucocorticoid receptor function aggravating glucocorticoid deficiency. Treatment of adrenal crisis is simple and highly effective consisting of i.v. hydrocortisone (initial bolus of 100 mg followed by 200 mg over 24 h as continuous infusion) and 0.9% saline (1000 ml within the first hour). Prevention of adrenal crisis requires appropriate hydrocortisone dose adjustments to stressful medical procedures (e.g. major surgery) and other stressful events (e.g. infection). Patient education is a key for such dose adjustments but current education concepts are not sufficiently effective. Thus, improved education strategies are needed. Every patient should carry an emergency card and should be provided with an emergency kit for parenteral hydrocortisone self-administration. A hydrocortisone pen would hold a great potential to lower the current barriers to hydrocortisone self-injection. Improved patient education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are expected to significantly reduce morbidity and mortality from adrenal crisis.

The effect of patient‐managed stress dosing on electrolytes and blood pressure in acute illness in children with adrenal insufficiency

2020 ◽  
Vol 93 (2) ◽  
pp. 97-103 ◽  
Author(s):  
Georgina L Chrisp ◽  
David J Torpy ◽  
Ann M Maguire ◽  
Maria Quartararo ◽  
Henrik Falhammar ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Adrenal Insufficiency ◽  
Acute Illness

Perioperative Glucocorticoid Therapy for Patients with Adrenal Insufficiency: Dosing Based on Pharmacokinetic Data

2020 ◽  
Vol 105 (3) ◽  
pp. e753-e761 ◽  
Author(s):  
Baha M Arafah
Keyword(s):  
Adrenal Insufficiency ◽  
Half Life ◽  
Current Practice ◽  
Volume Of Distribution ◽  
Glucocorticoid Therapy ◽  
Major Surgery ◽  
Pharmacokinetic Data ◽  
Healthy Individuals ◽  
Hormone Injection ◽  
Range Of Values

Abstract Background Perioperative glucocorticoid therapy for patients with adrenal insufficiency (AI) is currently based on anecdotal reports, without supporting pharmacokinetic data. Methods We determined the half-life, clearance, and volume of distribution of 2 consecutive intravenously (IV)-administered doses of hydrocortisone (15 or 25 mg every 6 hours) to 22 dexamethasone-suppressed healthy individuals and used the data to develop a novel protocol to treat 68 patients with AI who required surgical procedures. Patients received 20 mg of hydrocortisone orally 2 to 4 hours before intubation and were started on 25 mg of IV hydrocortisone every 6 hours for 24 hours and 15 mg every 6 hours during the second day. Nadir cortisol concentrations were repeatedly measured during that period. Results In healthy individuals, cortisol half-life was longer when the higher hydrocortisone dose was administered (2.02 ± 0.15 vs 1.81 ± 0.11 hours; P < 0.01), and in patients with AI, the half-life was longer than in healthy individuals given the same hydrocortisone dose. In both populations, the cortisol half-life increased further with the second hormone injection. Prolongation of cortisol half-life was due to decreased hydrocortisone clearance and an increase in its volume of distribution. Nadir cortisol levels determined throughout the 48 postoperative hours were within the range of values and often exceeded those observed perioperatively in patients without adrenal dysfunction. Conclusions Cortisol pharmacokinetics are altered in the postoperative period and indicate that lower doses of hydrocortisone can be safely administered to patients with AI undergoing major surgery. The findings of this investigation call into question the current practice of administering excessive glucocorticoid supplementation during stress.

scholarly journals Increased Cardiovascular Risk in Patients with Adrenal Insufficiency: A Short Review

2017 ◽  
Vol 2017 ◽  
pp. 1-5 ◽  
Author(s):  
Amir-Hossein Rahvar ◽  
Christian S. Haas ◽  
Sven Danneberg ◽  
Birgit Harbeck
Keyword(s):  
Cardiovascular Risk ◽  
Adrenal Insufficiency ◽  
Replacement Therapy ◽  
Interleukin 1 ◽  
Short Review ◽  
Blood Levels ◽  
Increased Risk ◽  
The World ◽  
Coronary Events ◽  
Necrosis Factor

Cardiovascular disease (CVD) is the most common cause of death in the world. Recent studies have shown an association between adrenal insufficiency (AI) and increased cardiovascular risk (CVR). Patients with AI receive glucocorticoid (GC) replacement therapy which can lead to varying levels of blood cortisol. It was shown that these imbalances in blood cortisol may lead to a higher prevalence of coronary heart disease, major adverse coronary events, and increased mortality. GC substitution is essential in the treatment of AI without which the disease has been shown to be fatal. The most frequently used GC formula for replacement therapy is hydrocortisone (HC). There is no uniform opinion on hydrocortisone replacement therapy. Alternative GC such as prednisolone is also in use. Overreplacement of GC may lead to adverse effects including obesity, high blood pressure, and hyperglycaemia. Outcome may vary between primary and secondary AI mainly due to differences in the renin-angiotensin-aldosterone system (RAAS). Furthermore, decreased blood levels of cortisol may lead to a compensatory secretion of inflammatory mediators such as Interleukin-1 (IL-1), Interleukin-6 (IL-6), and/or tumor-necrosis factor (TNF). Physicians and patients should be properly educated about the increased risk of CVD in patients with AI.

scholarly journals Frequently Asked Questions in Patients With Adrenal Insufficiency in the Time of COVID-19

2021 ◽  
Vol 12 ◽  
Author(s):  
Chiara Sabbadin ◽  
Corrado Betterle ◽  
Carla Scaroni ◽  
Filippo Ceccato
Keyword(s):  
Adrenal Insufficiency ◽  
Short Review ◽  
Acute Illness ◽  
Self Management ◽  
Vaccine Hesitancy ◽  
Adrenal Crisis ◽  
Risk Of Infection ◽  
Telemedicine Consultation ◽  
Life Threatening ◽  
Cortisol Deficiency

Adrenal insufficiency (AI) is a life-threatening disorder, with increased morbidity and mortality, especially in case of an acute illness that can increase the requirement of cortisol. A novel infectious disease, termed Coronavirus Disease 2019 (COVID-19), appeared in 2020. Therefore, AI patients are experiencing a novel challenge: the risk of infection. In our experience, a prompt contact to the Endocrine center (with a telemedicine consultation) and a full awareness of diseases (cortisol deficiency, COVID-19 and the self-management of an adrenal crisis) are important to motivate patients. Vaccine is an effective treatment to prevent hospitalization and aggressive course of COVID-19. Some patients manifest challenges due to inequitable access and vaccine hesitancy, resulting in a delay in the acceptance of vaccines despite the availability of vaccination services. Therefore, an effort of all physicians must be conducted in order to advise patients with AI. In this short review, we try to answer some frequently asked questions regarding the management of patients with AI.

scholarly journals Blood Levels of Free-Circulating Mitochondrial DNA in Septic Shock and Postsurgical Systemic Inflammation and Its Influence on Coagulation: A Secondary Analysis of a Prospective Observational Study

2020 ◽  
Vol 9 (7) ◽  
pp. 2056
Author(s):  
Emmanuel Schneck ◽  
Fabian Edinger ◽  
Matthias Hecker ◽  
Natascha Sommer ◽  
Oleg Pak ◽  
...  
Keyword(s):  
Septic Shock ◽  
Mitochondrial Dna ◽  
Observational Study ◽  
Systemic Inflammation ◽  
Secondary Analysis ◽  
Clinical Signs ◽  
Major Surgery ◽  
Blood Levels ◽  
Strong Positive Correlation ◽  
Potential Biomarker

Major surgery is regularly associated with clinical signs of systemic inflammation, which potentially affects the rapid identification of sepsis. Therefore, this secondary analysis of an observational study aims to determine whether NADH dehydrogenase 1 (ND1) mitochondrial DNA (mtDNA) could be used as a potential biomarker for the discrimination between septic shock and postsurgical systemic inflammation. Overall, 80 patients were included (septic shock (n = 20), cardiac artery bypass grafting (CABG, n = 20), major abdominal surgery (MAS, n = 20), and matched controls (CTRL, n = 20)). Quantitative PCR was performed to measure ND1 mtDNA. Thromboelastography was used to analyze the coagulatory system. Free-circulating ND1 mtDNA levels were significantly higher in septic shock patients compared to patients suffering from post-surgical inflammation ({copies/µL}: CTRL: 1208 (668–2685); septic shock: 3823 (2170–7318); CABG: 1272 (417–2720); and MAS: 1356 (694–2845); CTRL vs. septic shock: p < 0.001; septic shock vs. CABG: p < 0.001; septic shock vs. MAS: p = 0.006; CABG vs. MAS: p = 0.01). ND1 mtDNA levels in CABG patients showed a strong positive correlation with fibrinogen (correlation coefficient [r]= 0.57, p < 0.001) and fibrinogen-dependent thromboelastographic assays (maximum clot firmness, EXTEM: r = 0.35, p = 0.01; INTEM: r = 0.31, p = 0.02; FIBTEM: r = 0.46, p < 0.001). In conclusion, plasma levels of free-circulating ND1 mtDNA were increased in septic shock patients and were discriminative between sepsis and surgery-induced inflammation. Furthermore, this study showed an association between ND1 mtDNA and a fibrinogen-dependent pro-coagulatory shift in cardiac surgical patients.

scholarly journals Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness

2011 ◽  
Vol 37 (12) ◽  
pp. 1986-1993 ◽  
Author(s):  
Nienke Molenaar ◽  
A. B. Johan Groeneveld ◽  
Hilde M. Dijstelbloem ◽  
Margriet F. C. de Jong ◽  
Armand R. J. Girbes ◽  
...  
Keyword(s):  
Critical Illness ◽  
Adrenal Insufficiency ◽  
Total Cortisol ◽  
Cortisol Levels ◽  
Corticosteroid Secretion
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