UMEM Educational Pearls - By Caleb Chan

Category: Airway Management

Title: Critical Care Pearls for Adrenal Crisis

Keywords: Adrenal Crisis (PubMed Search)

Posted: 1/7/2020 by Caleb Chan, MD (Updated: 1/24/2020)
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Adequate treatment of adrenal crisis (AC) is often delayed, even when a h/o adrenal insufficiency is known.

  • most important predictor of AC is a h/o of AC

 

Besides refractory hypotension, also consider in pts with:

  • critically ill pts with eosinophilia (cortisol typically suppresses eosinophil counts)
  • cancer patients who are on check-point inhibitor immunotherapy (they can cause severe hypophysitis or adrenalitis)
  • (inhaled glucocorticoids and topical creams also cause a degree of adrenal insufficiency)

 

Beware of triggers:

  • trauma, recent surgery, even emotional stress/exercise
  • recent initiation of medications that increase hydrocortisone metabolism (avasimibe, carbamazepine, rifampicin, phenytoin, and St. John’s wort extract)
  • recent withdrawal of medications that decrease hydrocortisone metabolism (voriconazole, grapefruit juice, itraconazole, ketoconazole, clarithromycin, lopinavir, nefazodone, posaconazole, ritonavir, saquinavir, telaprevir, telithromycin, and conivaptan)

 

Treatment:

  • 100 mg IV hydrocortisone STAT as a loading dose, followed by 50 mg IV hydrocortisone q6h
  • can also give 40 mg IV methylprednisolone if hydrocortisone is not immediately available
  • can also give 4-6 mg IV decadron instead (will preserve integrity of ACTH stim test to diagnose adrenal insufficiency if it is performed later)

 

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Blood Transfusion Thresholds in Specific Populations

Sepsis - 7 g/dL

  • non-inferior to 9 g/dL (which was previously recommended in early goal-directed therapy and early Surviving Sepsis guidelines)

Acute Coronary Syndrome - no current specific recommendations pending further studies

  • recent MINT pilot study showed unexpected trend toward higher combined mortality and major cardiac events in restrictive transfusion arm (8 g/dL) vs. liberal arm (10 g/dL)

Stable Cardiovascular Disease - 8 g/dL

  • no difference in 30-day mortality compared to 10 g/dL, excluding those who have undergone cardiac surgery

Gastrointestinal Bleeds

  • UGIB - 7 g/dL (unless intravascularly volume depleted or h/o CAD)
    • better 6 week-survival, less re-bleeding compared to 9 g/dL
  • LGIB - 7 g/dL, limited evidence, but based on UGIB data

Acute Neurologic Injury - Traumatic Brain Injury - 7 g/dL

  •  no significant difference in neurologic recovery at 6 weeks or mortality vs. 10 g/dL, although there were more brain tissue hypoxia events in restrictive arm
  •  anemia and transfusions both associated with worse outcomes in TBI

Postpartum Hemorrhage - 1:1:1 ratio strategy

  • FFP/RBC ratio ≥  1 associated with improved patient outcomes

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The Kidney Transplant Patient in Your ED

  • Acute bacterial graft pyelonephritis is the most frequent type of sepis (bacterial pneumonia is the second most common source)
  • Obtain renal transplant imaging to evaluate for sources of infection (i.e. urinary tract obstruction, renal abscess, or urine leakage)
  • BK polyomavirus may reactivate and lead to nephritis, ureteral stenosis, or hemorrhagic cystitis
  • Pneumocystis pneumonia is the most common fungal infection in patients without prophylaxis and after prophylaxis discontinuation (adjunctive steroids for treatment is controversial)
  • Vascular access may be challenging. Avoid subclavian lines or femoral venous acess on the side of the graft
  • Cardiovascular disease is the leading cause of mortality (accounts for 40-50% of deaths after the first year following renal transplant)

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