1. Adrenal Crisis in the ICU
Kay Luft, MN, RN, CCRN
2012

2. What Do These Two Have in Common??

3. Case Study: Acute Adrenal Insufficiency
HPI: PJ, a 38-year-old female is admitted to the
ED complaining of progressive fatigue for two
weeks. She saw her primary physician four days
ago and was told that everything was fine on her
blood work-up and that her fatigue was due to
depression. She also complains of nausea and
vomiting and states she has lost about 16 pounds
in the past two weeks. She denies any fever, chills,
night sweats, cough, or dysuria. She becomes short
of breath when walking only 5 to 10 feet.
PMH: Mild hypertension; Premature ovarian
failure at age 30

4. Case Study: Acute Adrenal Insufficiency, Cont’d
Social History:
Single parent; 2 teenaged children who live with her
Lost job as insurance underwriter one month ago
Nonsmoker; drinks socially once per month
Physical Exam:
Vital signs: Blood pressure 86/40, Pulse 118, Respiration 18, Temp 99° F
Appears pale, dehydrated and malnourished
Rest of exam unremarkable

5. Case Study: Acute Adrenal Insufficiency Cont’d
Lab:
Na 129, K+ 5.7, Glucose 62, BUN 19, Creatinine 1.0
CT Scan of Abdomen:
Unable to visualize adrenal glands indicating atrophy
Plan of Care:
Send to the MICU for treatment and monitoring

6. What is this patient’s most likely medical diagnosis
What is this patient’s most likely medical diagnosis? What are the clues?

7. What Is Adrenal Crisis?
A medical emergency characterized by severe cardiovascular compromise, shock, coma, and possibly death
Is due to severe fluid and electrolyte imbalances related to decreased production of adrenocortical hormones as result of:
Impaired function of the adrenal glands (primary type)
Inadequate stimulation of the adrenal glands by the anterior pituitary (secondary type)

8. Causes of Adrenal Crisis

10. Summary of Causes of Adrenal Crisis
Exacerbation of Addison’s disease (chronic adrenal insufficiency) – often triggered by extreme stress or failure to comply with medication (steroids) regime
Acute physiologic stress: trauma, surgery, severe infection and/or illness
Bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome)
Adrenalectomy or hypophysectomy
Extreme psychological stress

11. Quick Review of Normal Adrenal Physiology

13. Pathophysiology of Adrenal Crisis
Adrenal crisis is associated with inadequate production or release of glucocorticoids (cortisol) and mineralocorticoids (aldosterone).
Adrenocortical hormones are necessary for maintaining normal glucose, sodium, and fluid balance in the body.
Aldosterone deficiency causes large urinary loss of sodium and water quickly leading to severe hyponatremia and hypovolemia.
As result of hyponatremia, hyperkalemia and metabolic acidosis often occur.

14. Pathophysiology of Adrenal Crisis, Cont’d
Hypovolemia is intensified by glucocorticoid deficiency as result of decreased vascular tone and decreased vascular response to circulating catacholamines (epinephrine & norepinephrine).
Cortisol depletion quickly leads to hypoglycemia as body is unable to maintain blood glucose levels in the fasting state.
Without treatment, severe hypotension, severe hypoglycemia, coma, and death will ensue.

15. Remember the Deficiency in 3 S’s:
Sodium (and water)
Sugar (glucose)
Steroid (esp. cortisol & aldosterone)

17. One Sick Puppy

18. Clinical Manifestations of Adrenal Crisis
Profound hypotension (especially postural)
Confusion
Muscle weakness
Fatigue, lethargy
Tachycardia
Decreased urinary output
Nausea, vomiting, diarrhea
Abdominal pain
Severe weight loss
Possible hyperthermia

19. Diagnostic Findings Related to Adrenal Crisis
Laboratory: hyponatremia (<137 mEq/L), hyperkalemia (>5 mEq/L), decreased serum glucose (<80 mg/L), decreased serum cortisol (<15 mcg/dl) & aldosterone levels, possible hypercalcemia
ECG: signs of hyperkalemia (peaked T waves, widened QRS, lengthened PR interval, flattened or absent p waves, possible asystole)

20. Diagnostic Findings Related to Adrenal Crisis
Hemodynamic: Decreased BP, CVP and PAWP; Increased heart rate; Consult physician for BP <90/60, CVP <2 mm Hg, PAWP <6 mm Hg, HR >120 bpm

21. ACTH Stimulation Test

22. Collaborative Treatment of Adrenal Crisis
Expected Outcomes (within 8 hours of initiating treatment):
BP within patient’s normal range
HR bpm
CVP 2-6 mm Hg
PAWP 6-12 mm Hg
Normal sinus rhythm on ECG
Patient alert and oriented
*** UO may not return to normal for a few days

23. Collaborative Treatment of Adrenal Crisis, Cont’d
Identification and Treatment of Initial Cause
Fluid Replacement
Rapid volume restoration is goal
D5NS is IV fluid of choice
Volume expanders (hetastarch) possible if hypotension persists

24. Collaborative Treatment of Adrenal Crisis, Cont’d
Glucocorticoid Replacement
Immediate IV bolus of Hydrocortisone (Solu-Cortef), followed by maintenance doses every 6 to 8 hours
Mineralocorticoid Replacement:
Generally unnecessary b/o mineralocorticoid effects of hydrocortisone
If emergency treatment needed, fludrocortisone is drug of choice

25. Collaborative Treatment of Adrenal Crisis, Cont’d
Glucose Replacement
Generally sufficient with IV fluids, but patient may need Dextrose 50% initially
Sodium Replacement
Generally sufficient with IV fluids, but patient may need NaHCO3 initially
Correction of sodium imbalance will shift K+ back into normal balance

26. Collaborative Treatment of Adrenal Crisis, Cont’d
Vasopressors
May be used if initial treatments are ineffective
Response to vasopressors, catecholamines, and inotropic agents is DECREASED for patients in adrenal crisis

27. Collaborative Treatment of Adrenal Crisis, Cont’d
Close monitoring of vital signs, PAP readings, lab results, cardiac rhythm, I&O, & neuro status
Oral & skin care
Promote rest

28. Back to Our Patient What treatment does PJ need INITIALLY?
What indicators will reflect improvement in PJ’s condition?
What follow-up care and teaching may PJ need?

29. Don’t Forget the Teaching!!

30. Questions??? Kluft@saint-lukes.org

31. References
Alspach, J. G. (2006). Core curriculum for critical care nursing (6th ed.). Philadelphia: W. B. Saunders.
McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). St. Louis: Elsevier/Mosby.
Schell, H. M., & Puntillo, K. A. (2006). Critical care nursing secrets (2nd ed.). St. Louis: Elsevier/Mosby.
Swearingen, P. L., & Keen, J. H. (1995). Manual of critical care nursing (3rd. ed.). St. Louis: Mosby.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2010). Critical care nursing: Diagnosis and management (6th ed.). St. Louis: Mosby.