Advertisement

Adrenal Insufficiency

  • Akhil Khosla
  • Amy M. AhasicEmail author
Chapter
  • 12 Downloads

Abstract

Adrenal insufficiency with acute crisis is a cause of shock in critically ill patients that may be underdiagnosed. Adrenal insufficiency may result from adrenal, pituitary, or hypothalamic disorders. Medications may also contribute to adrenal insufficiency. Critical illness-related corticosteroid insufficiency (CIRCI) is a relative adrenal insufficiency in which cortisol levels are inadequate for the acute critical illness and is discussed in Chap. 57. Diagnosis of adrenal insufficiency and differentiation of its various etiologies can be accomplished by measuring serum cortisol, ACTH levels, and by challenging the patient with exogenous adrenocorticotropic hormone (ACTH). Glucocorticoid replacement therapy is the mainstay of treatment, along with fluid resuscitation and supportive care. Salt repletion and glucose supplementation may be required, depending on the etiology of adrenal insufficiency. Mineralocorticoid replacement may also be necessary for primary adrenal insufficiency.

Keywords

Adrenal insufficiency Steroid replacement ACTH stimulation testing Addisonian crisis 

References

  1. 1.
    Bornstein SR. Predisposing factors for adrenal insufficiency. N Engl J Med. 2009;360(22):2328–39.CrossRefGoogle Scholar
  2. 2.
    Marik PE, Gayowski T, Starzl TE, Group HCRaAPS. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33(6):1254–9.CrossRefGoogle Scholar
  3. 3.
    Neary N, Nieman L. Adrenal insufficiency: etiology, diagnosis and treatment. Curr Opin Endocrinol Diabetes Obes. 2010;17(3):217–23.CrossRefGoogle Scholar
  4. 4.
    Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. Lancet. 2014;383(9935):2152–67.CrossRefGoogle Scholar
  5. 5.
    Asare K. Diagnosis and treatment of adrenal insufficiency in the critically ill patient. Pharmacotherapy. 2007;27(11):1512–28.CrossRefGoogle Scholar
  6. 6.
    Marik PE. Critical illness-related corticosteroid insufficiency. Chest. 2009;135(1):181–93.CrossRefGoogle Scholar
  7. 7.
    Annane D, Maxime V, Ibrahim F, Alvarez JC, Abe E, Boudou P. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med. 2006;174(12):1319–26.CrossRefGoogle Scholar
  8. 8.
    Hamrahian A. Adrenal function in critically ill patients: how to test? When to treat? Cleve Clin J Med. 2005;72(5):427–32.CrossRefGoogle Scholar
  9. 9.
    Oelkers W. Adrenal insufficiency. N Engl J Med. 1996;335(16):1206–12.CrossRefGoogle Scholar
  10. 10.
    Marik PE, Pastores SM, Annane D, Meduri GU, Sprung CL, Arlt W, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008;36(6):1937–49.CrossRefGoogle Scholar
  11. 11.
    Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004;350(16):1629–38.CrossRefGoogle Scholar
  12. 12.
    Jessop DS, Turner-Cobb JM. Measurement and meaning of salivary cortisol: a focus on health and disease in children. Stress. 2008;11:1–14.CrossRefGoogle Scholar
  13. 13.
    Dickstein G, Shechner C, Nicholson WE, et al. Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test. J Clin Endocrinol Metab. 1991;72(4):773–8.CrossRefGoogle Scholar
  14. 14.
    Dluhy RG, Himathongkam T, Greenfield M. Rapid ACTH test with plasma aldosterone levels. Improved diagnostic discrimination. Ann Intern Med. 1974;80(6):693–6.CrossRefGoogle Scholar
  15. 15.
    Lindholm J, Kehlet H. Re-evaluation of the clinical value of the 30 min ACTH test in assessing the hypothalamic-pituitary-adrenocortical function. Clin Endocrinol. 1987;26(1):53–9.CrossRefGoogle Scholar
  16. 16.
    May ME, Carey RM. Rapid adrenocorticotropic hormone test in practice. Retrospective review. Am J Med. 1985;79(6):679–84.CrossRefGoogle Scholar
  17. 17.
    Borst GC, Michenfelder HJ, O’Brian JT. Discordant cortisol response to exogenous ACTH and insulin-induced hypoglycemia in patients with pituitary disease. N Engl J Med. 1982;306(24):1462–4.CrossRefGoogle Scholar
  18. 18.
    Oelkers W, Diederich S, Bähr V. TI diagnosis and therapy surveillance in Addison’s disease: rapid adrenocorticotropin (ACTH) test and measurement of plasma ACTH, renin activity, and aldosterone. J Clin Endocrinol Metab. 1992;75(1):259.PubMedGoogle Scholar
  19. 19.
    Betterle C, Dal Pra C, Mantero F, Zanchetta R. Autoimmune adrenal insufficiency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction. Endocr Rev. 2002;23(3):327–64.CrossRefGoogle Scholar
  20. 20.
    Bornstein SR, Allolio B, Arlt W, Barthel A, et al. Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101:364–89.CrossRefGoogle Scholar
  21. 21.
    Schimmer BP, Funder JW. Adrenal steroids, and pharmacology of the adrenal cortex. In: Brunton LL, Chabner BA, Knollmann BC, editors. Goodman & Gilman’s: the pharmacological basis of therapeutics. 12th ed. New York, NY: McGraw-Hill Education; 2011.Google Scholar
  22. 22.
    Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003;361(9372):1881–93.CrossRefGoogle Scholar
  23. 23.
    Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288(7):862–71.CrossRefGoogle Scholar
  24. 24.
    Casserly B, Gerlach H, Phillips GS, Lemeshow S, Marshall JC, Osborn TM, et al. Low-dose steroids in adult septic shock: results of the surviving Sepsis campaign. Intensive Care Med. 2012;38(12):1946–54.CrossRefGoogle Scholar
  25. 25.
    Sligl WI, Milner DA, Sundar S, Mphatswe W, Majumdar SR. Safety and efficacy of corticosteroids for the treatment of septic shock: a systematic review and meta-analysis. Clin Infect Dis. 2009;49(1):93–101.CrossRefGoogle Scholar
  26. 26.
    Lipiner-Friedman D, Sprung CL, Laterre PF, Weiss Y, Goodman SV, Vogeser M, et al. Adrenal function in sepsis: the retrospective Corticus cohort study. Crit Care Med. 2007;35(4):1012–8.CrossRefGoogle Scholar
  27. 27.
    Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111–24.CrossRefGoogle Scholar
  28. 28.
    Walls RM, Murphy MF. Clinical controversies: etomidate as an induction agent for endotracheal intubation in patients with sepsis: continue to use etomidate for intubation of patients with septic shock. Ann Emerg Med. 2008;52(1):13–4.CrossRefGoogle Scholar
  29. 29.
    Policola C, Stokes V, Karavitaki N, Grossman A. Adrenal insufficiency in acute oral opiate therapy. Endocrinol Diabetes Metab Case Rep. 2014;2014:130071.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Schimke KE, Greminger P, Brändle M. Secondary adrenal insufficiency due to opiate therapy – another differential diagnosis worth consideration. Exp Clin Endocrinol Diabetes. 2009;117(10):649–51.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Section of Pulmonary, Critical Care and Sleep MedicineYale University School of MedicineNew HavenUSA
  2. 2.Section of Pulmonary, Critical Care and Sleep MedicineNorwalk Hospital, Nuvance HealthNorwalkUSA

Personalised recommendations