Relative Adrenal Insufficiency Hoa Nguyen, MD PGY2 05/2017

Objective Definition of relative adrenal insufficiency Diagnosing relative adrenal insufficiency Treatment of relative adrenal insufficiency Determine appropriate dosing needed

Case Problem 68 yo male with HTN and COPD presents to ER with AMS and cough with productive sputum for 1 day. T 39 degrees C, BP 70/35, HR 121, RR 21. He has been given 4L of NS and has been started on norepinephrine, with no improvement in his vitals. Which of the following next steps is most appropriate?

Draw random cortisol level Perform high dose ACTH stimulation test Administer hydrocortisone Administer hydrocortisone and fludrocortisone None of the above

Definition of Relative Adrenal Insufficiency Subnormal corticosteroid production during critical illness in the absence of structural defects in the hypothalamic-pituitary-adrenal axis

Diagnosing relative adrenal insufficiency Can be challenging and there is no consensus on diagnostic criteria or indications for treatment of this entity Plasma cortisol concentration and response to ACTH stimulation are unreliable in critically ill patients Diagnostic testing is not recommended

Treatment of relative adrenal insufficiency Corticosteroid therapy is indicated in only patients’ with severe septic shock (SBP<90 for more than 1 hours despite adequate fluid resuscitation and vasopressor administration) Give IV glucocorticoid therapy (hydrocortisone 200-300mg per day) Give for 5-7 days and taper dose based on clinical response Do not add fludrocortisone to regimen

Case 68 yo male with HTN and COPD presents to ER with AMS and cough with productive sputum for 1 day. T 39 degrees C, BP 70/35, HR 121, RR 21. He has been given 4L of NS and has been started on norepinephrine, with no improvement in his vitals. Which of the following next steps is most appropriate?

Answer Draw random cortisol level Perform high dose ACTH stimulation test Administer hydrocortisone Administer hydrocortisone and fludrocortisone None of the above Answer is C

Answer Draw random cortisol level Perform high dose ACTH stimulation test Administer hydrocortisone Administer hydrocortisone and fludrocortisone None of the above Answer is C

Summary Relative adrenal insufficiency is subnormal corticosteroid production during critical illness No reliable diagnostic test Most beneficial in patient with severe septic shock (SBP<90 for more than 1 hours despite adequate fluid resuscitation and vasopressor administration) Give IV glucocorticoid therapy (hydrocortisone 200-300 mg per day) in patients with severe septic shock for 5-7 days and taper as app

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