1 / 43

Postoperative Hypotension: acute adrenal crisis

Postoperative Hypotension: acute adrenal crisis. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Case #1. 21 yo morbidly obese man MVC BP 70, P 128, RR 20 c/o chest pain and pelvic pain PE: crepitus R chest wall R CT placed dislocated R shoulder

teva
Download Presentation

Postoperative Hypotension: acute adrenal crisis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Postoperative Hypotension:acute adrenal crisis Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

  2. Case #1 • 21 yo morbidly obese man MVC • BP 70, P 128, RR 20 • c/o chest pain and pelvic pain • PE: • crepitus R chest wall R CT placed • dislocated R shoulder • abdominal wall contusion • pelvic tenderness • Labs: Hct 40 ABG 7.29/42/151

  3. Case #1 • Studies • CXR - small R PTX with CT, multiple rib fxs • Pelvis - B rami fx • Lat Csp - neg • Cystogram - normal • CT ABD - left perinephric and pelvis hematoma, multiple pelvic fx • IV crystalloids/blood given

  4. Case #1 • T 39 C, SBP 90, UOP < 30 cc/hr • Resp. distress with tachypnea/hypoxia • Intubated • Started on dopamine and norepinphrine • ? Dx and plan

  5. Case #1 • Echo = normal • PA catheter • CI 8.5, Wedge 11, SVR 494 • Cultures sent • Exploratory laparotomy • nonexpanding retroperitoneal hematoma • ? Dx and plan

  6. Case #1 - Adrenal Insufficiency • Cortisol level drawn • Dexamethasone 10 mg IV given • Within hours, SBP > 100 off pressors , T 38C • UOP 800 cc/hr • Cortisol level 1.2 • Cosyntropin stim test: baseline 1.6, 60 min. 2.3 • Continued on glucocorticoid and mineralocorticoid

  7. Case #2 • 63 yom admitted with large cell diffuse lymphoma • CT scan - massive retroperitoneal lymphadenopathy • Given 4 drug chemotherapy • Developed fever 39, lethargy, and abdominal pain • ? Dx and plan

  8. Case #2 • Exploratory laparotomy • SB perforation from lymphoma • SB resection and primary anastomosis • POD1 extubated and doing well • POD 2 • hypotension, tachycardia, fever, and resp. distress • CXR - diffuse pulm edema • intubated • CV collapse despite IVF and dopamine/norepinephrine • ?Dx and plan

  9. Case #2 • PA catheter • CI 6, Wedge 22, SVR 350 • Repeat laparotomy performed • negative • ? Dx and plan

  10. Case #2 - Adrenal Insufficiency • Cortisol level drawn • Dexamethasone 10 mg IV given • Several hours dramatic improvement • SBP 140 and weaned from pressors • SVR 1000 • Cortisol baseline = 6, cosyntropin stim test = 7 • Hydrocortisone 100mg q 8hrs • D/C 1 month later on oral glucocorticoids

  11. Case #3 • 57 yo m s/p XRT with recurrent invasive bladder TCC • OR - radical cystectomy, ileal loop urinary diversion • POD 4 • DVT L leg • started on heparin qtt • prompt decrease in swelling and pain • POD 8 • LGI bleeding • HCT 31 to 19

  12. Case #3 • Heparin discontinued and FFP/Vit k given • Tagged red cell scan + ileoileal anastomosis • Transfused and HCT stabilized at 32/PLT 292K • Progression of DVT • restarted heparin for goal of 40 -50 • Developed fever 101, nausea, and LUQ pain • PE • BS decrease at L lung base • abdomen distended and tender LUQ • ? DX and plan

  13. Case #3 • CXR neg, EKG neg, VQ scan neg • LFT/amylase/lipase normal • PLT decreased to 60K - heparin stopped/IVC placed • POD 9-12 • abdominal complaints resolved • increased confused and disoriented • labs WNL with slowly resolving thrombocytopenia • developed hypotension, tachypnea, and fever 102

  14. Case #3 • Required intubation • Dopamine/norepinephrine qtt started • EKG and electrolytes WNL • WBC 23K • PA gram - negative • ? Dx and plan

  15. Case #3 • Dx ( preliminary) - septic thrombophlebitis • ABX started and slight improvement • Cultures sent and subsequently neg • Continued to deteriorate with fever/hypotension • Gallium scan - increased uptake L pelvis • Exploratory laparotomy - negative • ? Dx and plan

  16. Case #3 - Adrenal Insufficiency • Hydrocortisone given prior to OR • Prompt improvement • Fever resolved and BP returned to normal • Cosyntropin stim. test- low baseline, no response • Placed on dexamethasone • Required fludrocortisone for hyponatremia and hyperkalemia on restricted NA diet

  17. Postoperative Hypotension • Hemorrhage • Intravascular hypovolemia • Sepsis • Cardiac failure • Adrenal insufficiency

  18. ICU Adrenal disorders • Adrenal insufficiency (AI) • Pheochromocytoma and “ crisis” • Aldosterone deficiency

  19. Adrenal Insufficiency • Incidence • General population 40-60/million • ICU 1-20% • SICU 0.66% • SICU trauma 0.23% • SICU nontrauma 0.98% • SICU • > 14 days 6% • age > 55 1.7% • > 14 days and age > 55 11% • Blunt adrenal injury 5%

  20. Adrenal Insufficiency - AI • Primary • Central • Relative

  21. Primary AI • Pathological process within adrenal gland • 90% of gland destruction • Etiology • Autoimmune - 65-80% • Infectious - 35% • Hemorrhagic • Risk factors (Rao et al , Ann Intern Med, 1989) • coagulopathy • thromboembolic disease • postoperative state

  22. Central AI • Central dysfunction • pituitary (secondary) • hypothalamus (teritary) • Etiology •  long-term glucocorticoid therapy • uncommon • post-partum pituitary necrosis (Sheehan’s syndrome) • transient ACTH deficiency (alcoholics) • pituitary radiation • empty sella syndrome

  23. Relative AI • Relative • increased degradation of glucocorticoids • drugs that activate hepatic metabolism • treatment of hypothyroidism • resistance to glucocorticoid activity • AIDS • increased demand (stress response) • numerous ICU studies

  24. Risk Factors - AI • Age > 55 • Malnutrition • Prolonged hospital or ICU stay • Chronic alcoholism • High APACHE score • Stress in form of trauma, surgery, infection, and dehydration

  25. Presentation of AI • Non-ICU • insidious • nonspecific (weakness, wt loss, lethargy, GI symptoms) • ICU • acute adrenal crisis • altered by co-existing disease • usually precipitated by physical stressor (trauma, surgery, infection, dehydration) • other causes AIDS, TB, or pituitary tumor

  26. ICU Clinical Presentation • Refractory hypotension • High-output circulatory failure • CI > 4 • tachycardia • low SVR with normal wedge • Electrolytes disturbances • high K , low Na, and low glucose • Febrile (> 39C) • Mental status changes • Dehydration • GI disturbances

  27. “Clues” to AI • History • other endocrine abnormalities • family h/o endocrine abnormalities • Eosinophilia

  28. AI Differential Diagnosis • Sepsis • Neurogenic shock • Overdose of vasodilator • Severe anemia • AV shunt • Thyrotoxicosis • Beriberi • Pregnancy

  29. CRH + - - Cortisol - 10 mg/d ACTH + Hypothalamus-Pituitary-Adrenal Axis

  30. HPA Axis Assessment - Tests • H-P Axis and Adrenal • Low-dose ACTH stimulation (1 ug) • Adrenal only • Short ACTH stimulation test (250 ug) • H -P Axis only • Insulin-induced hypoglycemia test • Metyrapone • CRH stimulation

  31. Laboratory Assessment • Random cortisol level • draw before steroids given • draw between 6-8 am • decadron generally consider not cross-reactive • positive if < 10 in normal or < 15 in critically ill • 10-20 indeterminant • Cosyntropin testing • Corticotropin-releasing hormone test (CRH) • Plasma renin and aldosterone measurements

  32. Cosyntropin stimulation test • Standard short • baseline cortisol level • 0.25 mg cosyntropin with level 60 minutes later • peak > 20 or rise of 7 in critically ill • Low-dose short ( more sensitive for central) • more accurate and physiologic • same as standard but only 1 ug dose • Long • differentiation of primary vs central • replaced by ACTH measurement

  33. HPA Axis Assessment:Test Summary

  34. Diagnosis - AI in Critical illness Adrenal deficit Baseline ACTH Severe < 10 none Moderate 10-19 <30 Mild 20-30 <30 None > 30 >>30

  35. Treatment • Hemodynamically unstable • Baseline cortisol • Treat with Hydrocortisone 100 IV bolus and q8 • +/- cosyntropin testing • Isotonic IVF with D5 • treat underlying disease or precipitating factors • Hemodynamically stable • same as above • cosyntropin testing

  36. Treatment - Steroids • Hydrocortisone • provides glucocorticoid and mineralocorticoid • physiological doses • max 300 mg/day • normal daily adrenal output • AM 25 mg /PM 12..5 mg • Dexamethasone • not cross-reactive with cortisol assays • no mineralocorticoid activity • useful while diagnostic testing being completed • Fludrocortisone (Florinef) • uncommonly required for mineralocorticoid activity

  37. Steroid and Potency

  38. Glucocorticoid vs Mineralocorticoid • Steroid Glucocorticoid Mineralocorticoid Hydrocortisone 1 1 Prednisolone 4 0.7 Dexamethasone 40 2 Aldosterone 0.1 400 Fludrocortisone 10 400

  39. Potential for HPA Suppression • Higher risk for suppression • higher glucocorticoid potency • short frequency of dosing • evening dosing • systemic therapy • duration > 1 week

  40. Outcome • Untreated = 100% mortality • Treated in critically ill = 50% mortality • Cortisol level • positively correlated to severity of illness • negatively correlated to survival

  41. Prevention • Susceptible within 1-2 years of high dose glucocorticoids treatment • Presurgical screening • elderly patients • prolonged previous hospitalizations • malnourished or alcoholic patients • risk factors for adrenal insufficiency • prednisone doses > 5 mg/d • subnormal ACTH-stimulation test • previous adrenal insufficiency

  42. Prophylactic Steroid Therapy • Universal coverage most common • Lowest possible dose (perioperative) • Glowniak et al , Surgery, 1997 • prednisone maintenance dosing only • Salem et al, Ann Surgery, 1994 • minor surgery (hernia) = 25 -50 mg HC x 1 d • moderate (chole, TAH) = 50 -100 mg HC/d x 1-2 • major (Whipple, CABG) = 100-150 mg HC/d x 2-3 d • Decreased frequency ( qod if possible) • Am dosing (1/2 PM dosing only if needed)

  43. Postoperative Hypotension:acute adrenal crisisquestions…? Bradley J. Phillips, MD Burn-ICU Shriners Hospital for Children

More Related