Adrenal crisis is a can't-miss diagnosis. Prompt identification and proper management will generally lead to rapid improvement. The most important aspect is maintaining a high index of suspicion. When in doubt, start empiric therapy first and ask questions later.
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The IBCC chapter is located here.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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doesn’t seem to be a mention of relative adrenal insuff. in pts with no preexisting conditions and no catastrophic acquired conditions (death of adrenals, etc.). Is there going to be a chapter in the book on RAI and what the hell to do in sepsis? And make sure you link to the adrenal chapter in the IBCC TOC.
Will cover this in the chapter on sepsis. My current practice is to give metabolic resuscitation (hydrocort 50q6/ascorbate 1.5q6/thiamine 200q12) to almost all patients with sepsis unless there is some reason not to (e.g. AIDS, neutropenia). My impression is that this improves mortality but it’s impossible to say. What might be a more reasonable observation is that this gets folks better and out of the ICU really fast (e.g. rarely need midodrine anymore to boost patients off vasopressors). This might be of particular interest to ED-ICUs because if you start this stuff up-front I suspect it will increase the ability… Read more »
Why wouldn’t you give metabolic resuscitation to AIDS/neutropenia? Are there other scenarios you wouldn’t use Vit C cocktail? We’ve been using it pretty liberally with subjectively mixed but somewhat positive results.
Great write up btw!
Steroids in sepsis ??
Doesn’t it interfere with monitoring and body’s ability to fight sepsis??
How does ascorbate/ thiamine helps??
Thanks
I’m a big fan and love your posts but I’m not an apple guy. Is your podcast available on stitcher?
Second this! All previous episodes are downloadable from the site, would be great if that continues as I don’t have itunes either
You can download all episodes from the android podcast app as well, stream from Spotify, or if you want you can download directly from this site:
http://ibccpodcast.libsyn.com
I hope that helps.
Thanks for the information….
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Hello, sorry to post so late after the episode… Just one question/comment about your post: Timing to check for adrenal insufficiency after receiving Dexamethasone might be tricky.. although dexamethasone won’t interfere with the cortisol assay it does clearly suppress your axis. After asking around some colleagues and endos, I think that if the pt responds appropriately to an ACTH stim test after receiving dexa, you can rest assure there are no problems, However if there is not an appropriate response, the test should be repeated later on when the pt is tapered to physiological doses.. Some endos recommended trying to… Read more »
Chronic dexamethasone will suppress the adrenal gland, a process which takes some time.
One dose of dexamethasone won’t suppress the gland substantially, especially in the immediate term.
It’s fine to give a dose of dexamethasone and then do an ACTH stim test thereafter, the results should be adequate.