3 Case Study: Acute Adrenal Insufficiency HPI: PJ, a 38-year-old female is admitted to theED complaining of progressive fatigue for twoweeks. She saw her primary physician four daysago and was told that everything was fine on herblood work-up and that her fatigue was due todepression. She also complains of nausea andvomiting and states she has lost about 16 poundsin the past two weeks. She denies any fever, chills,night sweats, cough, or dysuria. She becomes shortof breath when walking only 5 to 10 feet.PMH: Mild hypertension; Premature ovarianfailure at age 30
4 Case Study: Acute Adrenal Insufficiency, Cont’d Social History:Single parent; 2 teenaged children who live with herLost job as insurance underwriter one month agoNonsmoker; drinks socially once per monthPhysical Exam:Vital signs: Blood pressure 86/40, Pulse 118, Respiration 18, Temp 99° FAppears pale, dehydrated and malnourishedRest of exam unremarkable
5 Case Study: Acute Adrenal Insufficiency Cont’d Lab:Na 129, K+ 5.7, Glucose 62, BUN 19, Creatinine 1.0CT Scan of Abdomen:Unable to visualize adrenal glands indicating atrophyPlan 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 deathIs 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)
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) regimeAcute physiologic stress: trauma, surgery, severe infection and/or illnessBilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome)Adrenalectomy or hypophysectomyExtreme psychological stress
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)
22 Collaborative Treatment of Adrenal Crisis Expected Outcomes (within 8 hours of initiating treatment):BP within patient’s normal rangeHR bpmCVP 2-6 mm HgPAWP 6-12 mm HgNormal sinus rhythm on ECGPatient 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 CauseFluid ReplacementRapid volume restoration is goalD5NS is IV fluid of choiceVolume expanders (hetastarch) possible if hypotension persists
24 Collaborative Treatment of Adrenal Crisis, Cont’d Glucocorticoid ReplacementImmediate IV bolus of Hydrocortisone (Solu-Cortef), followed by maintenance doses every 6 to 8 hoursMineralocorticoid Replacement:Generally unnecessary b/o mineralocorticoid effects of hydrocortisoneIf emergency treatment needed, fludrocortisone is drug of choice
25 Collaborative Treatment of Adrenal Crisis, Cont’d Glucose ReplacementGenerally sufficient with IV fluids, but patient may need Dextrose 50% initiallySodium ReplacementGenerally sufficient with IV fluids, but patient may need NaHCO3 initiallyCorrection of sodium imbalance will shift K+ back into normal balance
26 Collaborative Treatment of Adrenal Crisis, Cont’d VasopressorsMay be used if initial treatments are ineffectiveResponse 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 statusOral & skin carePromote 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?
31 ReferencesAlspach, 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.