Abrupt onset of adrenal crisis during routine preoperative examination in a patient with unknown Addison's disease

Risk of adrenal crisis in dental patients: results of a systematic search of the literature

BACKGROUND

The authors performed a systematic search of the literature to identify the frequency of, risk of experiencing and factors associated with adrenal crises in dental patients.

METHODS

The authors searched PubMed and Ovid MEDLINE (1947-June 20, 2012) and Embase (1974-2012) for English-language articles related to cases of adrenal crisis in dentistry and extracted and analyzed data from the articles. The six authors determined whether the cases identified met a consensus definition of adrenal crisis.

RESULTS

Of 148 articles identified in the initial screening, 34 articles were included in the final review, from which six cases met the criteria of adrenal crisis. The authors categorized four cases as "suggestive of adrenal crisis" and two cases as "consistent with adrenal crisis." Risk factors were significant adrenal insufficiency, pain, infection, having undergone an invasive procedure, having received a barbiturate general anesthetic, and poor health status and stability at the time of presentation. The authors estimated risk to be less than one in 650,000 in patients with adrenal insufficiency.

CONCLUSIONS

Adrenal crisis is rare in dental patients, with only six reports of it having been published in the past 66 years. Risk is associated with unrecognized adrenal insufficiency, poor health status and stability at the time of treatment, pain, infection, having undergone an invasive procedure and having received a barbiturate general anesthetic.

CLINICAL IMPLICATIONS

Risk of adrenal crisis is reduced through proper evaluation of the patient, identification of risk factors and following appropriate preventive measures.

Intra-operative diagnosis of hypopituitarism in a patient undergoing radical nephrectomy

A 43-year-old woman presented for elective radical nephrectomy. After induction of anaesthesia, she developed hypotension that failed to respond to standard treatment measures. Her core temperature decreased to 34 degrees C in spite of active warming. She required very low concentrations of anaesthetic agents to maintain an adequate depth of anaesthesia for abdominal surgery. After excluding the common causes of hypotension, the possibility of subclinical hypopituitarism was considered and subsequently confirmed.

Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsideration of the problem

BACKGROUND

Dental patients with primary or secondary adrenal insufficiency, or AI, may be at risk of experiencing adrenal crisis during or after invasive procedures. Since the mid-1950s, supplemental steroids in rather large doses have been recommended for patients with AI to prevent adrenal crisis.

METHODS

To evaluate the need for supplemental steroids in these patients, the authors searched the literature from 1966 to 2000 using MEDLINE and textbooks for information that addressed AI and adrenal crisis in dentistry. Reference lists of relevant publications and review articles also were examined for information about the topic.

RESULTS

The review identified only four reports of purported adrenal crisis in dentistry. Factors associated with the risk of adrenal crisis included the magnitude of surgery, the use of general anesthetics, the health status and stability of the patient, and the degree of pain control.

CONCLUSIONS

The limited number of reported cases strongly suggests that adrenal crisis is a rare event in dentistry, especially for patients with secondary AI, and most routine dental procedures can be performed without glucocorticoid supplementation.

CLINICAL IMPLICATIONS

The authors identify risk conditions for adrenal crisis and suggest new guidelines to prevent this problem in dental patients with AI.