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 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Eight patients admitted to a University hospital with acute surgical problems and related adrenal insufficiency were reviewed and three are presented in detail. Surgical stress and continued sepsis played major roles in the lack of responsiveness to usual modes of therapy until the adrenal insufficiency was corrected. The patients fell into three major clinical categories of adrenal insufficiency. Chronic illness and sepsis are shown to affect steroid production and metabolism, as well as adrenal responsiveness to ACTH. Pharmacologic amounts of steroids are often needed in patients with shock, gram negative sepsis and prolonged illnesses, even if normal or elevated serum cortisols are present. Therapeutic trials of cortisol administration are shown to be confusing when not accompanied by easily performed diagnostic tests of adrenal function. It is emphasized that a pretreatment serum cortisol should be obtained whenever possible. The evaluation of adrenal function is of lifelong importance to the patient.
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PMID:Occult adrenal insufficiency in surgical patients. 16 92

Hypoglycemia (h.) in the postneonatal period was predominantly observed in male infants and children. The incidence was 0,51/1000 hospitalizations. The majority of cases was found in the agegroup around 2 years. Concomitant diseases (mostly infections of the upper respiratory tract or gastrointestinal tract) were found in 30 out of 43 hospitalizations. Convulsions and coma were the most frequent symptoms which were found in 43%. In 30% some degree of somnolence was obvious. Hypoglycemia was not considered in the differential diagnosis in any case by the physician treating first. Only 7 out of 34 cases a complicated biochemical work up resulted in an etiological diagnosis: one leucininduced h.; one ketotic h,; one h. in dystrophy and bronchopneumonia with septicemia; one h. in meningococcic septicemia; one h. in adrenal insufficiency; one h. in isolated ACTH-deficiency; one ethyl-induced h.; one h. in polynesy of pancreas; one h. in insulinoma; one h. in diabetes mellitus under insulintherapy.
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PMID:[On the syndrome of childhood-hypoglycemia. II. Hypoglycemia in the postneonatal period (author's transl)]. 89 35

A 43-yr-old woman developed carcinoma of the ampulla of Vater 20 yr after being successfully treated for Hodgkin's disease with radiotherapy and chemotherapy. Conditions related to the chronic effect of radiation, such as narrowing and fibrosis of abdominal tissue, hampered her diagnosis and treatment. After a total pancreatectomy to remove the carcinoma, the patient recovered. However, 15 months later, she developed severe digestive disturbances, adrenal insufficiency, pulmonary emboli, and vasculitis. She died the next month of sepsis and adult respiratory distress syndrome. Although her complications probably were related to residual effects from therapy and surgery, she had no clinical evidence of tumor recurrence.
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PMID:Carcinoma of the ampulla of vater after curative treatment for Hodgkin's disease. 153 76

A 63-year-old white woman was admitted to the hospital for bilateral total knee arthroplasty. She was given prophylactic subcutaneous heparin therapy postoperatively. Three days later, she had a brief hypotensive episode and an unexplained drop in hemoglobin level. Seven days postoperatively, she became confused and disoriented while complaining of pain in her right side and, later, under her left breast. She also had nausea, vomiting, anorexia, and a vague feeling of "illness." Her condition deteriorated progressively, with blood pressure falling to 65/40 mm Hg and a temperature of 39.7 degrees C. Blood, urine, and cerebrospinal-fluid culture samples showed no evidence of infection. A diagnosis of acute adrenal insufficiency was made. Following corticosteroid therapy, the patient's condition improved markedly. Of interest in our patient was that she had had no antecedent hypotension, sepsis, fever, or surgical complications. Acute adrenal hemorrhage is often overlooked because the symptoms are attributed to other conditions, especially to sepsis. Acute adrenal hemorrhage should be suspected in any stressed patient in whom an abrupt deterioration associated with back or abdominal pain, hypotension, and unexplained fever are noted. Suspicion should be raised regarding those patients who are receiving anticoagulant therapy (including subcutaneous heparin prophylaxis) at the time of deterioration. With increased awareness, more cases of acute bilateral adrenal hemorrhage and subsequent adrenal insufficiency can be recognized ante mortem and treated.
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PMID:Prophylactic subcutaneous heparin therapy as a cause of bilateral adrenal hemorrhage. 155 45

Adrenal insufficiency is a deceptive disorder. Insidious in onset, chronic in nature, it can suddenly progress into an acute life-threatening condition that may mimic disorders of vastly different etiologies. The result can be a lethal delay in diagnosis. Prompt diagnosis and replacement of glucocorticoids and fluids are essential for survival. Acute adrenal insufficiency is frequently an exacerbation of an underlying chronic disorder of the adrenal cortex or pituitary gland. Yet any patient who has been treated with suppressive doses of glucocorticoids (e.g., cortisol, prednisone), experienced overwhelming sepsis, has received anticoagulant therapy, or has endstage metastatic carcinoma may suddenly develop adrenal insufficiency along with its deadly sequela of hypovolemic shock, hyperkalemia, hyponatremia, and hypoglycemia. Successful management of this condition requires not only a heightened clinical awareness of adrenal insufficiency, but effective stress reduction interventions and a thorough patient and family teaching program to support lifelong control of the disease.
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PMID:Adrenocortical insufficiency: a medical emergency. 157 31

The use of increased dosages of glucocorticoids during periods of physiologic stress in allograft recipients represents a clinical dilemma in that the short-term exogenous therapy required may significantly impair wound healing and immunocompetence. To investigate whether "stress steroids" are actually necessary, a prospective study was conducted in 40 renal allograft recipients admitted with significant physiologic stress. Stress categories included sepsis, metabolic abnormalities, and surgery. These patients received only their baseline prednisone immunosuppression (5-10 mg/day) and no supraphysiologic or stress doses of glucocorticoids. The clinical course of the patients revealed no evidence of adrenal insufficiency. There was no mortality, increase in hospital stay, or eosinophilia. Five episodes of hyponatremia and seven instances of hypotension were attributed to primary disease processes and responded promptly to specific treatment without steroid supplementation. Biochemical evaluation during stress revealed suppression of ACTH levels in 74.5% of episodes, elevation of urinary free cortisol levels in 79.1% of episodes, and elevation of isolated serum cortisol levels in 55.9% of episodes. This suggested that these patients had physiologically adequate adrenal function. The cosyntropin stimulation test overestimated the incidence and degree of clinically significant adrenal dysfunction (63% of patients) and was not a useful indication of a requirement for additional glucocorticoids. We conclude that functional adrenal suppression is uncommon in renal allograft recipients receiving baseline prednisone immunosuppression (5-10 mg/day) and that the demands of physiologic stress are met by a combination of endogenous adrenal function plus exogenous, baseline, immunosuppressive doses of glucocorticoids. Supra-physiologic or high doses of so-called "stress steroids" are not required. The cosyntropin stimulation test has significant clinical limitations and did not serve to alter clinical care.
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PMID:Adrenal suppression and steroid supplementation in renal transplant recipients. 184 49

The morbidity associated with adrenalectomy can be as high as 40% and the mortality is approximately 2% to 4%. Morbidity following adrenalectomy is associated with intraoperative injury to an adjacent or contiguous structure, postoperative infection, thromboembolism, or adrenal insufficiency. Mortality is most often associated with pulmonary emboli, sepsis, a myocardial event (myocardial infarction or arrhythmia), or as a direct result of the underlying disease for which adrenalectomy is being performed. The posterior approach to adrenalectomy is associated with less blood loss and morbidity, and is best tolerated by the patient. However, the anterior transabdominal approach offers superior access to both adrenals, as well as other pertinent abdominal and retroperitoneal sites, and structures requiring concomitant exploration.
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PMID:Complications following adrenal surgery. 200 53

We report two patients with fulminant meningococcal septicemia, in whom massive bilateral adrenal hemorrhages were diagnosed by ultrasound. Low plasma cortisol levels were found in one patient who eventually died. The other patient survived and has remained asymptomatic for the last three years. His adrenal function is normal. We suggest that routine ultrasound examination should be performed in patients with meningococcal sepsis and shock in order to clarify the prevalence of a renal hemorrhage. Determination of plasma cortisol levels in patients with adrenal hemorrhage, would allow identification of those with adrenal insufficiency who may benefit from steroid replacement.
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PMID:Sonographic diagnosis of adrenal hemorrhage in patients with fulminant meningococcal septicemia. 208 17

A seventy-five year-old woman developed adrenal hemorrhage and acute adrenal insufficiency while receiving anticoagulant therapy. Abdominal CT scan was consistent with bilateral adrenal hemorrhage and was an important contribution to diagnosis and therapy. Acute adrenal hemorrhage should be suspected in patients, especially the elderly, who have recently begun anticoagulant therapy and develop upper abdominal pain followed by decreased sensorium, high fever, hypotension, and hyponatremia. Any consideration of the diagnosis of sepsis with shock in a recently anticoagulated elderly hospital patient should suggest the possibility of acute adrenal hemorrhage. Abdominal CT scan and a cosyntropin stimulation test should be performed to confirm the diagnosis. Failure of diagnosis has generally been associated with death in most patients, whereas prognosis in patients treated with corticosteroids is excellent.
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PMID:Adrenal hemorrhage: a complication of anticoagulant therapy--a case history. 359 6

In spite of all the scientific and technical advances in recent years, shock that is not rapidly correctable with fluid can have a morbidity rate exceeding 80%. Consequently awareness of such precipitating factors as sepsis and early diagnosis and treatment are essential. Treatment should be rapid and should follow a previously outlined protocol. Such protocols should include correction of the precipitating problem and aggressive resuscitation to assure adequate ventilation and oxygenation of the blood and optimal oxygen delivery to the tissues. Fluid and blood should be given as needed until filling pressures begin to rise rapidly with further fluid infusion. With hemorrhagic shock in previously healthy individuals, a hemoglobin level of 10.0 g/dL is usually adequate. In older, septic, or cardiogenic shock patients, a hemoglobin level of 12.5 to 14.0 may be preferable. If an optimal preload does not increase cardiac output to normal or higher levels, inotropic agents should be used. If shock still persists, one must be sure that the arterial pH is not excessively high or low. Glucocorticoids may then be given in low dose (200 mg hydrocortisone) in case some degree of adrenal insufficiency is present. They can also be given in high doses (equivalent to 150 mg/kg hydrocortisone) early in septic shock primarily to prevent excess complement activation and to preserve membrane integrity. Vasopressors may occasionally be required if there is excessive vasodilation, especially if there is persistent hypotension in the presence of high-grade coronary or cerebral artery stenosis. Vasodilators may be used to try to correct myocardial ischemia (nitroglycerin), excessive preload (nitroglycerin), or excessive afterload (nitroprusside or hydralazine). Combinations of vasodilators and inotropic agents may be required in some patients with high systemic vascular resistance and persistently low cardiac outputs. Mechanical assist with IABP can be of great value in persistent cardiogenic shock. Diuretics may occasionally help prevent renal failure in patients who are persistently oliguric after blood flow and pressure are restored. Heparin is occasionally of value if DIC develops with no concomitant fibrinolysis. Antibiotics are important in septic shock and may also be important if persistent shock has reduced gastrointestinal mucosal integrity so that bacteria and bacterial products can enter the portal system.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Science and shock: a clinical perspective. 389 56


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