Acute adrenal insufficiency /certified fixed orthodontic courses by Indian dental academy

Acute Adrenal Insufficiency

INDIAN
DENTAL
ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Introduction
Cortisol – is secreted by Adrenal Cortex
- Functions
• Helps body to adapt to stress
• Extremely vital for survival
- Hyper secretion
CUSHINGS SYNDROME
» Buffalo hump
» Increased B.P.
» Eosino & Lymphopenia
» Not an acute life threatening condition
- Hypo secretion
Adreno Cortical insufficiency
life threatening condition

Adreno Cortical Insufficiency
- Secondary

- Primary
the defect is with
the gland itself
- C/a Addisons Disease

the gland parenchyma
is fully functional but
suppressed by certain
exogenous factors

-1st recognised by Addison
in 1844

Normal daily secretion of Cortisol is 20mg/ day
Acute Adreno Cortical Insufficiency is a Medical Emergency

Why is it a Medical Emergency
1. Glucocorticoid insufficiency
2. Peripheral vascular collapse (shock)
3. Ventricular asystole
•

Clinical manifestations DO NOT develop until at least
90% of the Adrenal Cortex is destroyed. Thus diagnosis
is usually late.

•

Condition is dangerous because patient is able to
maintain a basal level of cortisol, but in stressful
situations adequate cortisol is NOT produced and thus
acute Adreno Cortical Insufficiency develop.

Cortisol Regulation
•

•

Mainly by two methods
1. ACTH levels influenced by blood cortisol levels
2. ACTH – Diurnal variation
- start rising by 2 AM in people who sleep
at night & becomes maximum in the
morning.
Only under stressful situations
3. Stress
Hypothalamus
CRF
ACTH


Stress
Higher centers of brain

op
ath
P

ys
h

gy
olo
i

Hypothalamus
CRF

Anterior Pitutary stimulated
Increase in ACTH
Adrenal Cortex stimulated
Cannot produce Cortisol

Endogenous
Cortisol
decrease

Pre Disposing Factors
1. Sudden withdrawal of steroid hormones in a patient who
suffers from Addisons disease.
2. Sudden withdrawal of steroid hormones in a patient with
normal ardenals.
3. After Stress
• Physiologic – infection, trauma, surgery
• Psychologic
1. After B/L Adrenalectomy
2. After sudden destruction of pituitary gland
3. Direct injury to Adrenals – trauma, hemorrhage, infection

Sudden withdrawal of steroid hormones
in a patient with normal ardenals….
• Acute Adrenal Insufficiency is produced because
exogenous corticosteroids produce dysuse atrophy of
the adrenal cortex.
• This is Secondary Adreno Cortical Insufficiency


Return to Normal Functioning depends
upon …
1. WHICH corticosteroid was given
-

20 mg Hydocortisone = 5 mg Prednisolone
= 0.75 dexamethasone

-

Patients with Addisons disease require 15- 25
mg of hydrocortisone in 2 divided doses i.e. 2/3
in morning & 1/3 in evening

-

But patients suffering from diseases such as
arthritis receive 10 mg Prednisolone equivalent to
50 mg of Hydrocortisone
1. DOSE of exogenous corticosteroid administered

……

3. DURATION of treatment – any patient receiving
glucocorticoids for 2 weeks or more
4. How FREQUENTLY glucocorticoids were given
5. ROUTE of administration
- topical & intra articular injections do NOT suppress

adrenal cortex
- rest all route suppress adrenals

Always ask the patient …
•
•

Any corticosteroids taken within last 2 years
h/o
1. Allergy
Because in these conditions
2. Asthma
usually corticosteroids are given
3. Arthritis
4. Rheumatism


Rule of “Two”
•

Adreno Cortical Insufficiency may be suspected in a
patient who has received glucocorticoids
1. In a dose of 20 mg or more of cortisone or its
equivalent.
2. Oral or parenteral steroids for 2 weeks or more
3. Above two within 2 yrs of dental treatment


Clinical Features
• Males = Females
• Lethargy, fatigue, weakness
• Hyperkalemia
» skeletal muscle paralysis
• Decrease in blood pressure
• Mucocutaneous hyperpigmentation
• Orthostatic hypotension
• Anorexia
• Hypoglycemia
• In dental set up
» Progressive mental confusion
» pain in abdomen, lower back, legs

Criteria for Determination of
Adreno Cortical Insufficiency
• h/o current or recent long term steroid therapy
• Mental confusion
• Nausea & vomiting
• Abdominal pain
• Hypotension


Diagnosis
1. ACTH Stimulation Test
•

0.25 mg Cosyntropin ( synthetic ACTH )
administered at time 0.

•

Blood samples withdrawn at time 0, 1, 6-8 hrs

•

Normal Adrenal Cortex response is 3 times
increase in cortisol levels compared to basal
levels

1. Blood electrolytes testing
2. BSL

Management Overview
• Though all corticosteroids may be deficient,
administration of cortisol can treat most of the
pathophysiologic effects of Addisons disease.
• Patients with Addisons disease require life long
administration of glucocorticoids.
• Identify & prevent acute precipitation.


Definitive Management
In a CONCIOUS patient
1. Terminate the on going procedure
2. Position – supine with leg slightly elevated
3. ABC assess
4. Monitor vital signs
 You will see tachycardia and hypotension
5. Call physician
6. O2 - 5 – 10 Lts/ min
7. Adm. Glucocorticoid (only if the patient is a known
sufferer of insufficiency)
 Give 100 mg hydrocortisone I.V. over 30 sec
 Or 100 mg hydrocortisone I.M.

Treat other Problems
• Hypovolemia
» by 1Lt. of NS infused with in 1 hr.
• Patient may require upto 3 Lt. of fluids – to be given over
8 hours
• Hypoglycemia
» by 5% Dextrose


In an Unconscious Ptaient
1.
2.
3.
4.
5.
6.
7.

Shake & Shout
Position – supine with leg slightly elevated
ABC assess
O2 - 5 – 10 Lts/ min
Aromatic spirits – NH3
Call physician
Monitor vital signs
 You will see tachycardia and hypotension
8. Administer glucocorticoids
 100 mg glucocorticoid I.M./ I.V.
 Best if I.V. over 30 sec
 Also start I.V. infusion 100 mg hydrocortisone
administered over 2 hrs.
9. Shift to hospital www.indiandentalacademy.com

Prevention
• Stress Reduction Protocol
• If patient is taking steroids then increase the dose by 2
or 4 times on the day of dental treatment.


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Acute adrenal insufficiency /certified fixed orthodontic courses by Indian dental academy

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