Treatment of acute adrenal insufficiency

In acute adrenal insufficiency, it is urgent to use replacement therapy with synthetic drugs of gluco- and mineralocorticoid action, as well as to carry out measures to remove the patient from the shock state. In time, the treatment started leaves more opportunities to get the patient out of the crisis. The most dangerous for life are the first day of acute hypocorticism. In medical practice, there is no difference between the crisis in patients who developed with the aggravation of addison's disease after removal of the adrenal gland and a coma that occurred as a result of acute destruction of the adrenal cortex in other diseases.

From preparations of glucocorticoid action in conditions of acute adrenal insufficiency it is necessary to give preference to hydrocortisone. It is injected intravenously and drip, for this use hydrocortisone hemiscuic or adzizon (cortisone). For intramuscular administration, hydrocortisone acetate is used as a suspension. With an acute adrenal crisis, all three modes of administration of hydrocortisone are usually combined. Begin with hydrocortisone succinate - 100-150 mg intravenously struino. The same amount of the drug is dissolved in 500 ml of equal amounts of isotonic sodium chloride solution and 5% glucose solution and injected for 3-4 hours at a rate of 40-100 drops per minute. Simultaneously with the intravenous injection of water-soluble hydrocortisone, the suspension of the preparation is administered at a dose of 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. Within 1 day the total dose of hydrocortisone is from 400-600 mg to 800-1000 mg, sometimes more. Intravenous hydrocortisone is continued until the patient is withdrawn from collapse and the blood pressure rises above 100 mm Hg. And then continue intramuscular administration 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 up 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 introduction of glucocorticoids should be combined with the appointment of mineralocorticoids - DOXA (deoxycorticosterone acetate). The drug is administered intramuscularly at 5 mg (1 ml) 2-3 times in 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 must be remembered that the oil solution DOXA is absorbed slowly, the effect can appear only a few hours from the start of the injection.

Along with the introduction of hormones, therapeutic measures are taken to combat dehydration and shock phenomena. The amount of isotonic sodium chloride solution and 5% glucose solution on the 1st day is 2.5-3.5 liters. When repeated vomiting is recommended, intravenous administration of 10-20 ml of 10% sodium chloride solution at the beginning of treatment and repeated administration with severe hypotension and anorexia. In addition to the isotonic solution of sodium chloride and glucose, if necessary, appoint a polyglucone in a dose of 400 ml, blood plasma.

Inadequate treatment of addisonic crisis can be associated with a small dose of hormonal drugs or salt solutions or with a rapid reduction in dosage of drugs. The use of prednisolone in place of hydrocortisone, which has little effect on fluid retention, leads to a slower compensation of metabolic processes during the addisonic crisis.

Complications of hormonal therapy are associated with overdosage of drugs. The most frequent of them are edematous syndrome, swelling on the limbs, face, in the cavities, paresthesia, paralysis. These symptoms are associated with hypokalemia, and it is sufficient to reduce the dose of DOXA or temporarily cancel the drug, interrupt the administration of table salt, so that these symptoms decrease. In these cases, potassium chloride is administered in solution or in powder to 4 g / day, with acute hypokalemia, intravenous administration of a 0.5% solution of potassium chloride in 500 ml of a 5% solution of glucose is indicated. When brain swelling occurs, mannitol is injected, diuretics are indicated. An overdose of glucocorticoids is accompanied by the development of mental complications - from mood and sleep disturbance to expressed anxiety, sometimes occurring with hallucinations. Reducing the dose of corticosteroids to those who support it usually suppresses these psychic manifestations.

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

Forecast. Mortality with hemorrhages in the adrenals is high - up to 50%. The prognosis depends on the early correct diagnosis. Timely struggle against vascular collapse, sepsis and other causes that caused an acute crisis, makes the forecast not so hopeless, but after recovery, signs of adrenal insufficiency remain, and patients need lifelong replacement therapy with synthetic analogues of hormones - the adrenal cortex.

Prevention of acute adrenal insufficiency

Timely recognition and treatment of the initial or subacute insufficiency of the adrenal glands are important for preventing the progression of the crisis. The development of precursors of crisis or acute hypocorticism can be prevented in patients with chronic hypocorticism during large and small surgical interventions of infectious processes, during pregnancy, childbirth. For prophylactic purposes, parenteral administration of glucocorticoids and DOXA preparations in smaller doses is prescribed than with an addisonic crisis. The day before the operation, hydrocortisone is administered intramuscularly for 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 drip and 50 mg intramuscularly every 4-6 hours for 1-2 days. Parenteral administration of hydrocortisone is continued after the operation for 2-3 days. Then gradually transferred to substitution therapy with tablets of prednisolone, cortisone and DOXA. First the dose exceeds the usual, the duration depends on the general condition of the patient. When the severity of operational stress is eliminated, it is transferred to the doses of drugs used before the operation.