Adrenal Insufficiency, Acute
Description Diagnostic criteria Medicine treatment Referral ICD-10 Code: E27.4 DESCRIPTION Acute failure of adrenal function, suspected when a patient presents with hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia and metabolic acidosis. Patients on chronic steroid therapy are at risk for adrenal insufficiency if treatment is abruptly stopped. Increase steroid dose during times of s
ICD-10 Code: E27.4
DESCRIPTION
Acute failure of adrenal function, suspected when a patient presents with hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia and metabolic acidosis.
Patients on chronic steroid therapy are at risk for adrenal insufficiency if treatment is abruptly stopped.
Increase steroid dose during times of stress (fever, trauma and surgery) to prevent adrenal crisis (see below).
DIAGNOSTIC CRITERIA
Clinical
- Acute circulatory collapse. The features include:
- tachycardia,
- hypotension,
- pallor,
- poor peripheral perfusion,
- cool clammy skin,
- dehydration,
- coma,
- metabolic acidosis,
- decreased level of consciousness.
- A history of weakness, anorexia, vomiting, weight loss, salt craving, hyperpigmentation (primary adrenal insufficiency),
- Auto-immune endocrinopathies, steroid-dependence and ambiguous genitalia may be present.
- Hyperkalaemia
- Hypoglycaemia
- Hyponatraemia
- Hypercalcaemia (uncommon).
Investigations
Take blood for estimation of:
- Serum electrolytes and blood glucose.
- In all suspected cases, take a sample of clotted blood for estimation of plasma cortisol prior to treating the patient. Send this sample with the patient to the central hospital if laboratory facilities are not locally available.
MEDICINE TREATMENT
Stabilisation
For shock
- Sodium chloride 0.9%, IV, 20 mL/kg bolus as needed.
For hypoglycaemia
- Dextrose 10%, IV, 2–5 mL/kg bolus as needed.
- Hydrocortisone, IV, 2 mg/kg immediately as a single dose.
- Follow with 0.5 mg /kg/dose every 6 hours.
Manage hyperkalaemia. See: Nephrological/Urological Conditions, Acute kidney injury (Renal failure, acute).
Prevention
Patients on chronic steroid therapy are at risk of adrenal insufficiency during stressful situations e.g. sepsis, trauma, elective or emergency surgery. Increase the dose of steroids for the duration of the stressful period.
For major stress, e.g. > 39 °C:
- Treble hydrocortisone replacement until recovery (usually 3 days).
For minor stress, e.g. URTI, > 38 °C:
- Double hydrocortisone replacement until recovery (usually 3 days).
Adrenal insufficiency is a life threatening emergency.
REFERRAL
- All cases immediately after stabilisation.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 7: Endocrine, 7.3 Adrenal Insufficiency, Acute