Adrenal and Pituitary Emergencies

Recognition and Management of Adrenal Emergencies

Although clinical conditions associated with dysfunction of the ad-renal gland are often subtle, even insidious, in their presentation,and diagnosis and treatment usually are confined to outpatient clinics and offices, there are several situations that warrant the attention of emergency physicians. Recognition of the spectrum of presentations of pheochromocytoma, adrenal insufficiency, and pituitary apoplexy, and the sequelae of corticosteroid therapy and withdrawal, are critically important areas to emergency medicine. Prompt diagnosis with appropriate treatment and referral will reduce morbidity and mortality in many patients each year. A related topic pertinent to emergency physicians is the management of incidental adrenal masses that are discovered on abdominal radio-logic imaging.

The evaluation and management of shock

Shock is an emergency that requires continuous bedside evaluation, resuscitation, and re-evaluation. The initial bedside examination allows the clinician to determine whether the patient exhibits a clinical picture that is consistent with hypovolemic, cardiogenic, or vasodilatory shock. The primary survey dictates urgent initial resuscitation that usually consists of intubation, ventilation, and volume support. Vasoactive therapy is started when the patient is well volume-resuscitated and consists of inotropic support for cardiogenic shock and pressor therapy for vasodilatory shock. The secondary survey is helpful in revealing the cause of shock and necessary to institute early definitive therapy. Early shock has a hemodynamic component, which is often easily reversed. Septic shock and prolonged shock from any cause has an inflammatory component, which is not easily reversed and leads to multiple-system organ failure (MSOF) and death. Success in treatment of shock depends on early recognition of shock and the rapid tempo of resuscitation of its hemodynamic component to prevent or minimize the inflammatory component.

Adrenal insufficiency in high-risk surgical ICU patients

STUDY OBJECTIVES

To examine the incidence and response to treatment of adrenal insufficiency (AI) in high-risk postoperative patients.

DESIGN

Prospective observational case series.

SETTING

Large urban tertiary-care surgical ICU (SICU).

PARTICIPANTS

Adults > 55 years of age who required vasopressor therapy after adequate volume resuscitation in the immediate postoperative period.

INTERVENTIONS

Each patient underwent a cosyntropin (ACTH) stimulation test; at the discretion of the clinical team, some patients were empirically given hydrocortisone (100 mg IV q8h for three doses) before serum cortisol values became available.

MEASUREMENTS

Adrenal dysfunction (AD), defined as serum cortisol < 20 microg/dL at all time points, with Delta cortisol (60 min post-ACTH minus baseline) of < or = 9 microg/dL; functional hypoadrenalism (FH), defined as serum cortisol < 30 microg/dL at all time points or Delta cortisol (60 min post-ACTH minus baseline) < or = 9 microg/dL; and AI, as the presence of either AD or FH.

RESULTS

One hundred four patients were enrolled with a mean age (SD) of 65.2 +/- 16.9 years. AI (AD plus FH) was found in 34 of 104 patients (32.7%): AD was found in 9 patients (8.7%), FH in 25 patients (24%), and normal adrenal function in 70 patients (67.3%). The absolute eosinophil count was significantly higher in the combined AD and FH groups compared with the group with normal adrenal function (p < 0.05). Forty-six of 104 patients (44.2%) received hydrocortisone; 29 (63%) could be weaned from treatment with vasopressors within 24 h. This beneficial effect of hydrocortisone reached statistical significance in the FH group when compared with untreated patients (p < 0.031); a similar trend was seen in the AD group (p = 0.083). Mortality was also lower in the hydrocortisone-treated AI patients (5 of 23 [21%] vs 5 of 11 [45%] in those not receiving hydrocortisone; p < 0.01).

CONCLUSION

There is a high incidence of AI among SICU patients > 55 years of age with postoperative hypotension requiring vasopressors. There is also a significant association between hydrocortisone replacement therapy, resolution of vasopressor requirements, and improved survival.

Spontaneous haemorrhage into an empty sella turcica mimicking pituitary apoplexy

We present a case of spontaneous haemorrhage into an empty sella turcica with the features of subclinical pituitary apoplexy. A 66-year-old woman with a previously resected pituitary adenoma presented four months later with progressive headache and visual deterioration. Cranial MRI demonstrated hyperacute blood products in a recurrent pituitary adenoma. Operative findings were of subacute blood in an empty sella turcica. There was no operative or subsequent histological evidence of tumour recurrence. The intrasellar haemorrhage was evacuated via a trans-sphenoidal approach, resulting in a rapid improvement in visual function. Endocrine deficits required thyroxine, corticosteroid and desmopressin supplementation. Haemorrhage into an empty sella turcica has not been previously described and needs to be suspected as a clinical entity in patients presenting with the features of pituitary apoplexy. Awareness of this clinical condition will prevent preoperative misdiagnosis.