Question 17

Last updated 24/04/2023 - 22:43
 Topic: Endocrinology Metabolism and Nutrition
Pass rate
59.6%
Other SAQs in this topic:
Other SAQs in this paper:

a) List five causes of an Addisonian crisis. (20% marks)
b) List five laboratory abnormalities of an Addisonian crisis. (20% marks)
c) Outline the priorities of treating an Addisonian crisis. (60% marks)

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College answer

Answers in part a) were commonly around causes of Addison's disease rather than causes or precipitants of an adrenal crisis. Some candidates listed more than the number asked in part a), and this is a reminder to trainees that if the question asks for five answers, and candidates list more than five, only the first five answers will be considered.

Discussion

a) Of these six causes, at least five should be correct:

  • Insufficient supplementation
    • Poor medication compliance for chronic steroid replacement
    • Abrupt weaning of long term steroids
    • Decreased oral steroid absorption (eg. bowel obstruction)
  • Increased demand
    • Acute infection
    • Surgery or trauma
    • Pregnancy

b) Laboratory abnormalities:

  • Hyponatremia
  • Hyperkalemia
  • Metabolic acidosis (NAGMA)
  • Raised urea (due to volume depletion)
  • Hypoglycaemia
  • Hypercalcemia

c) Management priorities:

  • Immediate priorities:
    • Steroid replacement: hydrocortisone 100mg IV immediately, followed by 50mg four times a day
      • In patients with suspected adrenal insufficiency who do not yet have a diagnosis, giving emergency dexamethasone may be an option, because it will not interfere with cortisol measurements (or, one may simply send a cortisol level and then immediately start hydrocortisone)
    • Volume replacement: isotonic saline, titrated to clinical response
    • Glucose replacement: dextrose, to aim for normal BSL
  • Supportive management:
    • Correct hypotension with vasopressors (noradrenaline) 
    • Correct hyperkalemia with standard measures (cation exchange resin, insulin, salbutamol, etc)
      • Add fludcorotisone if using dexamethasone instead of hydrocortisone
    • Cease any medications that may be precipitating the crisis, eg. any CYP 3A4 inducers, azoles, etomidate, rifampicin, carbamazepine

References

Oh's Intensive Care manual: Chapter   61   (pp. 660) Adrenocortical  insufficiency  in  critical  illness by Balasubramanian  Venkatesh  and  Jeremy  Cohen

Oelkers, Wolfgang. "Adrenal insufficiency." New England Journal of Medicine335.16 (1996): 1206-1212.

Marik, Paul E. "Mechanisms and clinical consequences of critical illness associated adrenal insufficiency." Current opinion in critical care 13.4 (2007): 363-369.

Cooper, Mark Stuart, and Paul Michael Stewart. "Adrenal insufficiency in critical illness." Journal of intensive care medicine 22.6 (2007): 348-362.

Marik, Paul E., and Gary P. Zaloga. "Adrenal insufficiency in the critically ill: a new look at an old problem." CHEST Journal 122.5 (2002): 1784-1796.

Dorin, Richard I., Clifford R. Qualls, and Lawrence M. Crapo. "Diagnosis of adrenal insufficiency." Annals of Internal Medicine 139.3 (2003): 194-204.

Feeney, C., et al. "Addisonian crisis: assessment and management." British Journal of Hospital Medicine 79.3 (2018): C34-C37.

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