Treatment of acute adrenal insufficiency

In acute adrenal insufficiency, it is necessary to urgently use replacement therapy with synthetic drugs of glucocorticoid and mineralocorticoid action, as well as to carry out measures to bring the patient out of the state of shock. Timely treatment leaves more opportunities to bring the patient out of the crisis. The most life-threatening are the first day of acute hypocorticism. In medical practice, there is no difference between a crisis in patients that occurs during an exacerbation of Addison's disease after removal of the adrenal glands, and a comatose state that occurs as a result of acute destruction of the adrenal cortex in other diseases.

Of the glucocorticoid drugs in conditions of acute adrenal insufficiency, preference should be given to hydrocortisone. It is administered intravenously by jet and drip, for this purpose hydrocortisone hemisuccinate or adreson (cortisone) are used. For intramuscular administration, hydrocortisone acetate is used in the form of a suspension. In acute adrenal crisis, all three methods of hydrocortisone administration are usually combined. They start with hydrocortisone succinate - 100-150 mg intravenously by jet. The same amount of the drug is dissolved in 500 ml of equal amounts of isotonic sodium chloride solution and 5% glucose solution and administered drip over 3-4 hours at a rate of 40-100 drops per 1 min. Simultaneously with intravenous administration of water-soluble hydrocortisone, a suspension of the drug is administered at 50-75 mg every 4-6 hours. The dose depends on the severity of the condition and the results of increasing blood pressure, normalizing electrolyte disturbances. During the first day, the total dose of hydrocortisone is from 400-600 mg to 800-1000 mg, sometimes more. Intravenous administration of hydrocortisone is continued until the patient is brought out of collapse and blood pressure increases above 100 mm Hg, and then its intramuscular administration is continued 4-6 times a day at a dose of 50-75 mg with a gradual decrease in the dose to 25-50 mg and an increase in the intervals of administration to 2-4 times a day for 5-7 days. Then patients are transferred to oral treatment with prednisolone (10-20 mg / day) in combination with cortisone (25-50 mg).

The administration of glucocorticoids should be combined with the administration of mineralocorticoids - DOXA (deoxycorticosterone acetate). The drug is administered intramuscularly at 5 mg (1 ml) 2-3 times on the 1st day and 1-2 times on the 2nd day. Then the dose of DOXA is reduced to 5 mg daily or after 1-2 days. It should be remembered that the oil solution of DOXA is absorbed slowly, the effect may appear only after several hours from the start of the injection.

Along with the introduction of hormones, therapeutic measures are taken to combat dehydration and shock. The amount of isotonic sodium chloride solution and 5% glucose solution on the first day is 2.5-3.5 liters. In case of repeated vomiting, intravenous administration of 10-20 ml of 10% sodium chloride solution is recommended at the beginning of treatment and repeated administration in case of severe hypotension and anorexia. In addition to isotonic sodium chloride solution and glucose, if necessary, polyglucon is prescribed in a dose of 400 ml, blood plasma.

Insufficient effectiveness of treatment of Addisonian crisis may be associated with a low dose of hormonal drugs or salt solutions or with a rapid reduction in the dosage of drugs. The use of prednisolone instead of hydrocortisone, which has little effect on fluid retention, leads to a slower compensation of metabolic processes during Addisonian crisis.

Complications of hormonal therapy are associated with drug overdose. The most common of them are edema syndrome, edema of the extremities, face, cavities, paresthesia, paralysis. These symptoms are associated with hypokalemia, and it is enough to reduce the dose of DOXA or temporarily stop the drug, interrupt the administration of table salt, so that these symptoms decrease. In these cases, potassium chloride is prescribed in solution or powder up to 4 g / day, in acute hypokalemia, intravenous administration of 0.5% potassium chloride solution in 500 ml of 5% glucose solution is indicated. In case of cerebral edema, mannitol is administered, diuretics are indicated. Overdose of glucocorticoids is accompanied by the development of mental complications - from mood and sleep disorders to severe anxiety, sometimes occurring with hallucinations. Reducing the dose of corticosteroids to maintenance usually stops these mental manifestations.

Symptomatic therapy is performed. If the crisis is caused by infectious diseases, antibacterial therapy with broad-spectrum antibiotics and sulfanilamide drugs is used. To compensate for cardiopulmonary insufficiency, intravenous infusions of corglucon and strophanthin are used in adequate doses under electrocardiogram control.

Prognosis. Mortality from adrenal hemorrhages is high - up to 50%. The prognosis depends on early and correct diagnosis. Timely treatment of vascular collapse, sepsis and other causes of acute crisis makes the prognosis less hopeless, however, after recovery, signs of adrenal dysfunction remain, and patients require lifelong replacement therapy with synthetic analogs of hormones - adrenal cortex.

Prevention of acute adrenal insufficiency

Timely recognition and treatment of initial or subacute adrenal insufficiency are important for preventing crisis progression. Development of crisis precursors or acute hypocorticism can be prevented in patients with chronic hypocorticism during major and minor surgeries, infectious processes, pregnancy, and childbirth. For prophylactic purposes, parenteral administration of glucocorticoids and DOXA preparations is prescribed in smaller doses than in Addisonian crisis. The day before surgery, hydrocortisone is administered intramuscularly at 25-50 mg 2-4 times a day, DOXA - 5 mg / day. On the day of surgery, the dose of the drug is increased 2-3 times. During surgery, hydrocortisone is administered - 100-150 mg intravenously by drip and 50 mg intramuscularly every 4-6 hours for 1-2 days. Parenteral administration of hydrocortisone is continued after surgery for 2-3 days. Then gradually transfer to replacement therapy with tablets of prednisolone, cortisone and DOXA. At first the dose exceeds the usual, the duration depends on the general condition of the patient. When the severity of the surgical stress is eliminated, he is transferred to the doses of drugs used before the operation.