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2. 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
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3. 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
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4. 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.
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5. 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
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6. 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
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Endogenous
Cortisol
decrease
7. 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
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8. 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
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9. 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
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……
10. 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
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11. 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
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12. 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
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13. 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
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14. Criteria for Determination of
Adreno Cortical Insufficiency
• h/o current or recent long term steroid therapy
• Mental confusion
• Nausea & vomiting
• Abdominal pain
• Hypotension
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15. 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
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16. 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.
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17. 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.
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18. 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
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19. 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
20. 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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