Adrenal Insufficiency in the Critically Ill.ppt

Adrenal Insufficiency in the Critically Ill Presented by Ri 胡婉妍 Incidence of adrenal insufficiency in the critically ill patients Incidence varied according to the underlying disease, severity and diagnostic criteria Overall incidence≒30%, 50~60% in patients with septic shock Important actions of glucocorticoids during stress Metabolic properties ↑blood glucose, delivery of glucose to cells, hepatic gluconeogenesis ↑ Free fatty acid and amino acid release Cardiovascular system Angiotensin, epinephrine, norepinephrine -maintain cardiac contractility, vascular tone and BP Required for the synthesis of ATP, catecholamine, catecholamine receptors ↓NO (↓vasodilatation , permeablitly) Anti-inflammatory and immunosuppressive actions ↓accumulation and functions of most immune cells at inflammatory sites Modulate production or activity of cytokines other inflammatory mediators Enhance release of anti-inflammatory factors Causes of Acute AI in the critically ill Diagnosis of HPA Failure Clinical Features of Acute HPA Failure Diagnostic clues to AI Hemodynamic instability despite adequate fluid resuscitation Ongoing inflammation without obvious source Multiple organ dysfunction Hypoglycemia Eosinophilia Lab investigations Cutoff value? Vary with type severity of disease Change of CBG levels Tissue resistance to corticosteroid varies Both high low cortisol level are associated with poor prognosis Threshold: minimal 15ug/dl maximal 34ug/dl Lab Investigations Method? Gold standard: insulin tolerance test -infeasible in ischemic heart disease, epilepsy, severe cortisol deficiency Classical : iv 250 ug cosyntropin ↓ measure cortisol level 0, 30, 60 min later Investigation Algorithm Treatment of Acute AI NEJM (2003) CHEST(2002) Septic shock 50mg hydrocortisone IV q6h +fludrocortisone 5