Kenny-Joe WallenThe 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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