_adrenal insufficiency急性肾上腺皮质功能不全课件

+ Adrenal Insufficiency (AI) in the Septic Patient Fady Youssef, MD PGY-2 2014 + Objectives nDefine adrenal insufficiency nUnderstand who gets Relative adrenal insufficiency nReview the current evidence nUnderstand how to manage “Relative adrenal insufficiency” in the setting of sepsis. + Case Problem 68 yo male with PMH 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? nA: Draw a random cortisol level nB: Perform a high dose ACTH stimulation test nC: Administer hydrocortisone nD: Administer hydrocortisone with fludrocortisone nE: None of the above + Definition nAcute reversible dysfunction of the HPA axis in the setting of physiologic stress (e.g. sepsis, intra/post operative state) nIt is estimated that _ % of critically ill patients suffer from HPA axis dysfunction n30% nSymptoms of AI nshock, abdominal pain, fever, nausea and vomiting, electrolyte disturbances and, occasionally, hypoglycemia + Who gets AI? nAny patient in the setting of physiologic stress nEtiology: nAdrenal ACTH resistance nDecreased responsiveness of the target tissue to glucocorticoids (GC) nSecondary AI: 2/2 chronic steroid therapy (dose dependent) nCertain meds: Etomidate, Phenytoin, Ketoconazole + HPA Axis Where is the dysfunction occurring in secondary AI? 2ry AI + Diagnosing Relative Adrenal Insufficiency nDiurnal variation is LOST during physiological stress nLab assays of plasma cortisol concentration and ACTH stimulation test are unreliable in critically ill patients nRandom serum cortisol: Varies widely in critically ill patients. nIncreased mortality with both very low and very high cortisol levels nThere is are no reliable tests for diagnosing relative adrenal insufficiency. + So when to start steroid therapy? nLow MAP or SBP: requiring vasopressors nResponse to vasopressors is irrelevant to whether steroids should be started or not nAll meta-analyses confirmed improved shock reversal with low-dose corticosteroid use (trials listed below for further reference) nResponsiveness is defined as: maintaining MAP 65 mmHg without vasopressor use within 1 day of starting hydrocortisone nDont delay treatment for ACTH stim test + Treatment in sepsis nHydrocortisone: total of 200 300 mg over 24 hrs n50 100 mg q6-8h for 5-7 days with taper nPatients receiving higher doses of steroids had worse outcomes (citation below) n Fludrocortisone (a mineralocorticoid) has not been shown to help in relative adrenal insufficiency. nHydrocortisone seems to have sufficient mineralocorticoid activity nCOIITSS trial + 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? nA: Draw a random cortisol level nB: Perform a high dose ACTH stimulation test nC: Administer hydrocortisone nD: Administer hydrocortisone with fludrocortisone nE: None of the above + Summary nNo diagnostic test is reliable for relative adrenal insufficiency. nLow threshold to treat relative adrenal insufficiency in patients with septic shock nUse low dose hydrocortisone/physiologic dosing for a limited time nFludrocortisone has not been shown to help in relative AI + Interested? Here is more HPA axis Normal response nPhysiological stress activates the HPA axis which in turn increases serum cortisol levels nSerum Cortisol levels remain elevated during stress due to several factors: nReduced activity of cortisol metabolizing enzymes nRenal dysfunction prolonging the half l