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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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symptoms which might indicate a space-occupying lesion resulting in secondary insufficiency. In addition, it is also important to take a thorough drug history and ask specificallyaboutsteroiduse,includingIV,oral,topical,andinhaledformulations.
Acutesymptoms
In anacuteadrenalcrisis,inaddition tothesymptomspreviouslylisted,patientstendto be weak and clinically shocked, with an impaired mental state ranging from mild confusiontocomatose.
If the patient is acutely unwell and adrenal insufficiency is suspected, proceed directlytomanagementanddonotwaitfortheresultsof investigationsto confirm thediagnosis.
Examination
Fig.14.1showstheexaminationfindingsseeninchronicadrenalinsufficiency.Fig.14.2
showstheadditionalfindingswhichmaybeseeninanacuteadrenalcrisis.
Look in the palmar creases, at the nipples, at old scars, and in the mucous membranes for hyperpigmentation.
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Fig.14.1Examinationfindingsinchronicadrenalinsufficiency.
Fig.14.2Additionalexaminationfindingsinanacuteadrenalcrisis.
Investigations
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Bedside
HeartrateandECG Lyingandstandingbloodpressure.
Bloods
FBC(normochromicanaemiaandsometimeslymphocytosisand/oreosinophilia) U&E(kidneyinjuryandhyponatraemiainprimaryandsecondaryinsufficiencyandhyperkalaemia inprimaryinsufficiency) Calcium(low) Glucose(low) ESR(high) Cortisol(low)andadrenocorticotropichormone(ACTH)levels(highinprimarydisease,lowin secondary)—ideallyat9am.SeeBox14.2. TFT(thyroid-stimulatinghormone(TSH)maybehigh—seekspecialistadvice,orlow).SeeBox
14.3.
Box14.2Adrenocorticotropichormonetesting
TheACTHsamplesshouldbetakenatthesametimeastheserumcortisol,andshould betakendirectlytothelaboratory.Itisworthwhilecallingthelaboratoryfirsttoaskif theyhave anyspecial containers, e.g. containing ice, in which to transport the ACTH sample.
Box14.3Thyroidfunctiontests
Nevertreatthyroidabnormalitiespriortocorrectionofadrenalinsufficiencyasthismay precipitateacrisis.
Other
ShortSynacthentest—ifhaemodynamicallystable.SeeBox14.4 Serum aldosterone(low) and plasmarenin(high) (ifprimaryadrenalfailure;this can be useful withtheACTHtesttodifferentiatetheunderlyingcause).
Box14.4ShortSynacthentest
Usefulifa9amcortisolleveliswithinthenormalrangebutnot>400nmol/L(excludes thediagnosis).
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Note history of asthma/allergic disorder and ensure resuscitation facilities are available for possibleanaphylaxis MeasurebasalcortisolFIRST(thismaybecombinedwith testingACTHifnotalreadytested andifthetestisperformedat9am)
Administer250microgramsSynacthen™IM Repeatserumcortisolmeasurements30minutesaftertheSynactheninjection Failureofthecortisolmeasurementtoadequatelyrise(cut-offsdependonlocal laboratory but usually an incremental rise of 200nmol/L or 30-minute value >430nmol/L) suggests adrenal insufficiency.Ifcortisolislow,araisedACTHmeasurementindicatesprimaryinsufficiencyand alowACTHmeasurementindicatessecondaryinsufficiency.
Management
Acutemanagement
DONOTdelaytreatmentwhilewaitingforinvestigations.
Steroid
Hydrocortisone100mgIV/IMimmediately:
Afterthestatdosegivehydrocortisone200mgasacontinuousinfusionevery24hoursOR Hydrocortisone50mgIV/IMfourtimesdaily(QDS).
Fluids
1L 0.9% sodium chloride rapidly over 1 hour unless contraindicated (caution if renal/cardiac impairmentorelderly),andthencontinuefluidstotreatdehydration.
Treatmentafterstabilization
Refer to the endocrinology team for advice about switching the patient to oral hydrocortisone,usuallyafter72hours,commencingfludrocortisone(50–300micrograms OD, required in primary insufficiency only) and identifying the cause of the adrenal insufficiency.
Arrangeregularfollow-upintheendocrineclinic.
Education
Priortodischarge:
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2.
Discuss the need for lifelong steroid therapy and the risk of an acute crisis if the therapy is suddenlystoppedorreduced Signpost to support organizations, e.g. Addison’s self-help group (ADSHG;
https://www.addisonsdisease.org.uk/)
Explainthesickdayrules(Box14.5)andexplainthatfailuretofollowthemmayleadtoanacute crisis
Explaintheneedfor↑hydrocortisoneasperioperativetreatment Ensure the patient has an adequate supply of oral hydrocortisone so that they will be able to
double their dose if needed, and provide the patient with 100mg hydrocortisone IM for use in emergencies.EnsuretheyknowhowandwhentoadministertheIMdose(Box14.5)
Providethepatientwithasteroidemergencycard(see‘Furtherreading’)which should bepresentedtoanyhealthcareprofessionalthatthepatientcomesintocontactwith,and discusstheimportanceofmedicalalertdevices(e.g.bracelets).
Box14.5Sickdayrules
DoublethedoseofhydrocortisoneifthepatientisillwithafeverORneedstotakeantibiotics If oral hydrocortisone cannot be swallowed or metabolized, e.g. vomiting (more than one episode)ordiarrhoea,thepatientwillneedtohaveadoseof100mgIMhydrocortisone,even
iftheyhavealreadyhadtheirregularoraldose,andtheyshouldseekmedicalhelp.
Source:datafromArltW,etal.(September2016)SocietyforEndocrinologyEndocrineEmergency Guidance:Emergencymanagementofacuteadrenalinsufficiency(adrenalcrisis)inadultpatients. EndocrineConnections5(5):G1–G3.
Specialconsiderations
Specialistadviceshouldbesoughtinpregnancy.Ingeneral,thehydrocortisonedosewill needtobe↑inthethirdtrimesterandfordelivery.
Furtherreading
1. Turner HE, Eastell R, Grossman A (eds) (2018). Adrenal gland. In: Oxford Desk Reference:
Endocrinology (pp. 134–203). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199672837.003.0006
2. Society for Endocrinology (2020). New NHS Steroid Emergency Card. Available at:
https://www.endocrinology.org/endocrinologist/137-autumn-20/society-news/new-nhs-steroid­emergency-card-available-to-order/
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Chapter15
Diabeticketoacidosis
Guideline: Joint British Diabetes Societies Inpatient Care Group (The
management of diabetic ketoacidosis in adults): http://www.diabetologists-
abcd.org.uk/JBDS/JBDS_IP_DKA_Adults_Revised.pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Diabeticketoacidosis(DKA)occursmostfrequently,butnotexclusively,inpatientswith type 1 diabetes mellitus (T1DM). It is a medical emergency which typically resolves within24–48hoursifrecognized andtreatedappropriately. Themanagementof DKAin childreniscoveredinChapter75.
Diagnosis
History
DKA may be the presenting finding of T1DM. Alternatively, it may develop due to an insulindeficiency(e.g.insufficientdosingofinsulin),orduetoanincreaseddemandfor insulin(e.g.infection,surgery,medications,pregnancy,oraninflammatorystate).
Typically,patientscanpresentwithanyofthefollowingsymptoms:
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Drowsiness/confusion Vomiting Abdominalpain Polyuria Polydipsia Lethargy Anorexia.
Diagnosticcriteria
Diagnostic criteria for DKA are summarized in Fig. 15.1. Alternative presentations are discussedinBox15.1.
Fig.15.1Diagnosticcriteriafordiabeticketoacidosis.
Box15.1AlternativepresentationsofDKA
ConsiderDKAinallunwellpatientswithanelevatedglucoselevel,evenintheabsence ofsymptoms.
DKA should also be considered in unwell patients with type 2 diabetes mellitus (T2DM) who are taking SGLT2 inhibitors, e.g. dapagliflozin, empagliflozin, canagliflozin. These drugs can cause DKA with a normal glucose level (euglycaemic DKA).
Hyperglycaemichyperosmolarstate(HHS;seeChapter18)istypicallyassociatedwith dehydration andhyperglycaemia,without significantketosisor acidaemia;however,it mayalsooccurincombinationwithDKA.
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Examination
The main examination finding is dehydration due to the combination of vomiting, and osmotic diuresis. Signs of DKA precipitants (e.g. infection) may also be found (Table
15.1).
Table15.1PossibleexaminationfindingsinDKA
A
Maybecompromisedif↓GCSscore
B
Tachypnoea (attempted respiratory compensation for metabolic acidosis), progressing to Kussmaul’s respiration(rapidanddeep) Oxygensaturation(maybe↓ifthereisachestinfection) Signsofchestinfection,e.g.inspiratorycrackles,wheeze
C
Hypotension Tachycardia Prolongedcapillaryrefilltime Reducedorabsentjugularvenouspulse Reducedskinturgoranddrymucousmembranes Reducedurineoutput
D
GCS/AVPUscore(↓inseveredehydrationorsepsis)
E
Fever(contributestowardscausingdehydrationandindicatesinfection) Othersystemsexaminationtolookforprecipitatinginfection
Investigations
Investigations should centre around diagnosing DKA and assessing the severity (Box
15.2).DiscusswithcriticalcareearlyinsevereDKA,particularlyifthepatientisdrowsy.
OnceDKAisdiagnosed,considerwhatmayhavebeentheprecipitatingcause.
Bedside
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Point-of-carecapillarybloodglucose(CBG) Point-of-carebloodketones ECGandcontinuouscardiacmonitoring Urine:
Urinalysis, and send for microscopy, culture, and sensitivity (MC&S) if a urinary tract infectionissuspected Beta-humanchorionicgonadotropin(βHCG)testforpregnancy
Weight.
Bloods
FBC U&E LFT Venousbloodglucose Bloodcultures Venousbloodgas(VBG);alternativelyarterialbloodgas(ABG;ifoxygensaturationislowanda chestinfectionissuspected).
Imaging
ChestX-ray(ifachestinfectionissuspected).
Box15.2SevereDKAcriteria
Bloodketones>6mmol/L Bicarbonate<5mmol/L BloodpH<7.0 Aniongap>16:
Equation=(Na++K+)–(Cl–+HCO
3
–
)
Potassium<3.5mmol/Lonadmission GCSscore<12/abnormalAVPUscore Oxygensaturation<92%onair(if>94%isnormalforthepatient) Systolicbloodpressure<90mmHg Pulse<60bpmor>100bpm.
Source:datafromTheManagementofDiabeticKetoacidosisinAdults.September2013–JBDS02.
Management
Acutemanagement
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PatientswithsevereDKA(Box15.2)shouldbe reviewedbya senior clinicianand may requirehigherdependencycare.
Ifthepatientisdrowsy,considerinsertinganasogastrictubetoreducetheriskofaspiration.
IVfluids
Commence0.9%salinepriortocommencingafixedrateinsulininfusion(FRII).
Itisidealtohaveatleastonelarge-borecannulainalargevein.
Hypotension(systolicbloodpressure<90mmHg)
Give500mL0.9%salineover10–15minutes Repeatifstillhypotensiveandthenrequesturgentseniorreview.
Normotensive(systolicbloodpressure≥90mmHg)
Fluidshouldbeadministeredaggressivelyunlessthepatienthasriskfactors (Box15.3), in which case a more cautious approach may be needed (which may require higher dependencycare):
1L0.9%salineover1hourANDTHEN 1L0.9%salinewithpotassiumchlorideover2hoursANDTHEN 1L0.9%salinewithpotassiumchlorideover2hoursANDTHEN 1L0.9%salinewithpotassiumchlorideover4hoursANDTHEN 1L0.9%salinewithpotassiumchlorideover4hoursANDTHEN 1L0.9%salinewithpotassiumchlorideover6hoursANDTHENcontinuemonitoringasoutlined under‘Potassium’.
Box15.3Riskfactorswhereslowerfluidmayberequired
Age18–25years(carefulfluidreplacementtoavoidcerebraloedema) Veryelderly(toavoidfluidoverload) Pregnant Cardiacorrenalfailure Anothersignificantcomorbidity.
Source:datafromTheManagementofDiabeticKetoacidosisinAdults.September2013–JBDS02.
Potassium
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