© 2018 Kurt Pfeifer.

Adrenal Insufficiency (AI)

ASSESSMENT

Data Gathering

History

Symptoms

  • Cause of adrenal insufficiency disease 

  • Recent glucocorticoid use

  • Past, long-term glucocorticoid use

  • Adrenal insufficiency or unexplained severe hypotension after previous surgery

  • Fatigue

  • Generalized weakness

  • Weight changes

  • Palpitations

  • Edema

  • Abdominal pain

Exam

  • Orthostatic hypotension/tachycardia

  • Skin hyperpigmentation

Risk Stratification

Diagnostic Studies

  • BMP within 6 months (or more recently if change in clinical status) if known or suspected AI

  • Suspected AI:

    • AM cortisol: if >10 mcg/dl, can rule out AI (Schmidt et al)

    • ACTH-stimulation testing if adequate time to perform testing

MANAGEMENT

Indications for Surgical Delay

  • Elective surgery and suspected, undiagnosed adrenal insufficiency

Medication Management

  • Very little evidence is available to guide the best perioperative management of adrenal insufficiency risk - recent review (Groleau et al) and Cochrane review found no evidence of benefit from "stress dose" steroids but too little data to refute the possible benefit

  • Also no good evidence suggesting harm from administration of high-dose glucocorticoids for short periods (though hyperglycemia may occur)

  • ACR/AAHKS guideline for perioperative management of rheumatoid arthritis patients specifically advises against "stress dose" steroids

  • Majority of expert opinion provides recommendations similar to those shown in the table below

AI management.jpg
Steroid Equivalents - blue.jpg