1. Acute Adrenal Insufficiency
Alex Farhat

2. Objectives Define relative adrenal insufficiency
Understand who gets relative adrenal insufficiency.
Understand how to manage “relative adrenal insufficiency” in the setting of sepsis.

3. Case Problem
68 yo male with pmxh of HTN, HL 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?

4. A: Draw a random cortisol level
B: Perform a high dose ACTH stimulation test
C: Administer hydrocortisone
D: Administer hydrocortisone with fludrocortisone
E: None of the above

5. Relative Adrenal Insufficiency
Primary, secondary, tertiary and relative adrenal insufficiency are all different etiologies that cause malfunction of the HPA axis.

6. Relative Adrenal Insufficiency
Physiological stress activates the HPA axis.
Should theoretically increase cortisol production under normal circumstances.
However, other aspects of severe illness, as in sepsis, can alter production of cortisol.
Inflammatory cytokines and renal dysfunction are presumed causes of suppression of the HPA axis during sepsis.
This is a separate entity from adrenal crisis. If patient has adrenal crisis you will automatically give steroids. In this situation, there is a suppressed steroid response from inflammatory state, renal dysfunction etc.

7. Diagnosing Relative Adrenal Insufficiency
ACTH simulation test and serum cortisol levels are unreliable tests for diagnosing relative adrenal insufficiency.
There is no reliable test for diagnosing relative adrenal insufficiency.

8. Treatment in sepsis
Physicians should have a very low threshold for giving glucocorticoid (such as hydrocortisone) once vasopressors are started.
Map<65 or SBP<90.
Fludrocortisone (a mineralocorticoid) has not been shown to help in relative adrenal insufficiency.
Low map or SBP despite the initiation of vasopressors is indication. Even if map and sbp at goal, steroids should at least be considered once vasopressors are started.

9. Summary
Relative adrenal insufficiency is a different phenomenon than adrenal insufficiency.
No diagnostic test is reliable for relative adrenal insufficiency.
Low threshold to treat relative adrenal insufficiency in septic patients.
Fludrocortisone has not been shown to help

10. Case Problem
68 yo male with pmxh of HTN, HL 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?

11. A: Draw a random cortisol level
B: Perform a high dose ACTH stimulation test
C: Administer hydrocortisone
D: Administer hydrocortisone with fludrocortisone
E: None of the above
Answer is C