Adrenal insufficiency in Critical care

Management of Adrenal insufficiency in Critical care scenario by Dr. Om J Lakhani
00:00 🚂 Insights into the complexity and importance of understanding adrenal insufficiency in critically ill settings; it can often be a matter of life and death.
02:05 💉 Explanation of treatment plan for patients with pre-existing adrenal insufficiency that become critically ill.
04:37 📊 Discussion of the complications in assessing cortisol levels in ICU patients due to reduced cortisol binding globulin and albumin.
08:39 ⚕️ Explanation of primary, secondary, and tertiary adrenal insufficiency.
12:19 🧪 Description of an adrenal cortisol stimulation test, used to determine adrenal insufficiency.
14:09 🏥 Presentation of a case of "empty sella syndrome" caught via DHES assessment.
16:14 🔄 Mentioning the utility of DHEAS in patients already on hydrocortisone treatment.
17:35 🧠 Explanation of differentiating between primary, secondary and tertiary adrenal insufficiency using the ACTH level.
19:55 🦠 Discussion on the use of glucocorticoid in refractory septic shock and the controversial nature of its efficacy.
22:32 ⚖️ Noting the inconclusive nature of studies and meta-analysis involving the use of steroids in refractory septic shock.
26:09 🏥 Introduction of CIRCI (critical illness-related corticosteroid insufficiency) and its impact on long-term critically ill patients.
27:18 💊 Explanation on iatrogenic adrenal insufficiency and the possible drug causes.
30:06 🎯 Presentation of current guidelines on diagnosing CIRCI, including specific cut-offs for cortisol levels.
31:42 💡 Recommendation of lower steroid dose in treating CIRCI to avoid excess suppression of the endogenous HP Axis.
33:04 📌 Mention of the addition of fludrocortisone in patients with hyperkalemia suspected of primary adrenal insufficiency.
34:11 💊 Introduction of a cost-effective ACTH stimulation test using a drug called Acton Prolongatum, primarily used in India.
34:39 💉 Introduction of a cost-effective ACTH stimulation test in India using an intramuscular drug called Acton Prolongatum, which has been found to be as effective as the standard test.
35:06 🚀 Overview of how Sun Pharma in India brought in the standard ACTH stimulation test drug, Synacthen, to India around 2017-2018, but also noted the current global shortage of the drug.
36:57 📚 Emphasizing the importance of assessing adrenal insufficiency and how a missed diagnosis can be fatal.
37:40 📝 Summary of the steps in diagnosing adrenal insufficiency including a baseline cortisol, DHEA-S, and an ACTH stimulation test.
37:54 💭 Encouragement to consider the three different situations that might arise in a patient - undiagnosed adrenal insufficiency, refractory septic shock, or CIRCI.
38:22 🛑 Warning of the potential for iatrogenic adrenal insufficiency in critically ill patients due to drugs like etomidate, azoles, and glucocorticoids.
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🎯 Key Takeaways for quick navigation:
00:00 🏥 *Understanding Adrenal Insufficiency in Critically Ill Settings*
- Introduction to the topic of adrenal insufficiency in a critical care scenario,
- Distinguishing between three groups within critical illness: stress dosing for pre-existing adrenal insufficiency, acute septic shock not responding to vasopressors, and critical illness-related corticosteroid insufficiency.
02:33 💊 *Addressing Adrenal Insufficiency in Critical Illness *
- Importance of identifying pre-existing adrenal insufficiency in patients to provide appropriate stress dosing of hydrocortisone during a medical crisis,
- The need to transition back to routine hydrocortisone dosing as the patient recovers.
05:05 🔍 *Physiological Changes in ICU *
- Explanation of physiological changes in ICU impacting cortisol levels,
- An understanding of why ICU patients are different from non-ICU patients.
07:13 📚 *Case Study: Schmidt Syndrome*
- *Introduction to a case involving Schmidt Syndrome, *
- *Importance of recognizing adrenal Insufficiency and treating it before addressing hypothyroidism.*
08:39 ⚕️ *Understanding Adrenal Insufficiency Types*
- Explanation of three types of adrenal insufficiency: primary, secondary, and tertiary,
- Listing potential causes for each type, including long-standing steroid use or diseases affecting the pituitary gland.
11:24 📈 *Using Dehydroepiandrosterone (DHE) Ratio to Indicate Adrenal Insufficiency*
- Using DHE ratio as an indicator of adrenal insufficiency,
- Explanation of how it's calculated and why it's useful for diagnoses, especially in ICU settings.
14:50 💡 *Importance of Using DHE over Cortisol in ICU Settings *
- Advantages of DHE over cortisol in ICU settings due to its stability,
- Emphasizing the need to consider DHE values when diagnosing adrenal insufficiency.
16:28 💡 *Importance of Dehydroepiandrosterone (DHE)*
- Discussion of assessing adrenal insufficiency in critically ill patients,
- The importance of DHE in diagnosis, especially in ICU settings,
- Explanation of how DHE ratio can indicate adrenal insufficiency.
18:32 🏥 *Case Study: Septic Shock*
- Overview of a case study involving a patient with septic shock,
- Discussion of the controversial nature of glucocorticoid use in such scenarios,
- Examination of current guidelines and controversy surrounding steroid usage in ICU.
22:32 ⚖️ *Controversies in Steroid Use*
- Examination of differing trials and resulting debates about steroid use,
- Explanation of recent approach trial which found benefits of hydrocortisone and fludrocortisone,
- Discussion of controversies and current understanding based on clinical practice.
24:08 📘 *Understanding Cirsi*
- Introduction to a case study of critical illness-related corticosteroid insufficiency (Cirsi),
- Comparison of acute refractory septic shock and Cirsi,
- Emphasis on need for deliberate and thorough assessment in Cirsi diagnosis.
26:37 🎯 *Diagnosis of Cirsi*
- Description of conditions and symptoms to suspect Cirsi,
- Detailed understanding of Cirsi diagnosis processes and guidelines,
- Mention of the controversy surrounding the upper limit of cortisol.
29:51 👩‍⚕️ *Treating Cirsi*
- Recommended treatment strategies and dosage for Cirsi based on guidelines,
- Emphasis on planning for the tapering of steroids,
- Discussion about when to add fludrocortisone in the treatment process.
32:51 💉 *Act Stimulation Test and its Adoption in India *
*- Overview of the Act Stimulation test and its use in diagnosing adrenal insufficiency.*
*- Explanation of an alternative approach using the drug Acton Prolongatum.*
*- Mention of the introduction of Synacthen (standard steroid for ACT test) in India.*
34:52 🏥 *The Challenges and Costs of ACT Tests*
*- Discussion about the global shortage of Synacthen and its impact on conducting ACT tests.*
*- Cost comparisons between different drugs used for ACT tests.*
*- Explanation of the billing process for ACT tests in hospitals.*
36:43 💡 *Dehydroepiandrosterone's Impact on ACT Tests*
*- Observation of DHE's role in reducing the need for ACT tests in patients.*
*- Explanation of the importance and complexity of diagnosing adrenal insufficiency.*
37:54 🧠 *Classification of Adrenal Insufficiency Patients*
*- Summary of different situations of adrenal insufficiency: diagnosed/undiagnosed, refractory septic shock, and CIRCI.*
*- Emphasis on determining the right situation before proceeding with treatment options.*
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[@EndocrinologyIndia]

🎯 Key Takeaways for quick navigation:
00:00 🚂 *Insights into the complexity and importance of understanding adrenal insufficiency in critically ill settings; it can often be a matter of life and death.*
02:05 💉 *Explanation of treatment plan for patients with pre-existing adrenal insufficiency that become critically ill. *
04:37 📊 *Discussion of the complications in assessing cortisol levels in ICU patients due to reduced cortisol binding globulin and albumin.*
08:39 ⚕️ *Explanation of primary, secondary, and tertiary adrenal insufficiency.*
12:19 🧪 *Description of an adrenal cortisol stimulation test, used to determine adrenal insufficiency.*
14:09 🏥 *Presentation of a case of "empty sella syndrome" caught via DHES assessment. *
16:14 🔄 *Mentioning the utility of DHEA in patients already on hydrocortisone treatment.*
17:35 🧠 *Explanation of differentiating between primary, secondary and tertiary adrenal insufficiency using the ACTH level. *
19:55 🦠 *Discussion on the use of glucocorticoid in refractory septic shock and the controversial nature of its efficacy.*
22:32 ⚖️ *Noting the inconclusive nature of studies and meta-analysis involving the use of steroids in refractory septic shock. *
26:09 🏥 *Introduction of CIRCI (critical illness-related corticosteroid insufficiency) and its impact on long-term critically ill patients.*
27:18 💊 *Explanation on iatrogenic adrenal insufficiency and the possible drug causes.*
30:06 🎯 *Presentation of current guidelines on diagnosing CIRCI, including specific cut-offs for cortisol levels.*
31:42 💡 *Recommendation of lower steroid dose in treating CIRCI to avoid excess suppression of the endogenous HP Axis.*
33:04 📌 *Mention of the addition of fludrocortisone in patients with hyperkalemia suspected of primary adrenal insufficiency.*
34:11 💊 *Introduction of a cost-effective ACTH stimulation test using a drug called Acton Prolongatum, primarily used in India.*
34:39 💉 *Introduction of a cost-effective ACTH stimulation test in India using an intramuscular drug called Acton Prolongatum, which has been found to be as effective as the standard test.*
35:06 🚀 *Overview of how Sun Pharma in India brought in the standard ACTH stimulation test drug, Synacthen, to India around 2017-2018, but also noted the current global shortage of the drug.*
36:57 📚 *Emphasizing the importance of assessing adrenal insufficiency and how a missed diagnosis can be fatal. *
37:40 📝 *Summary of the steps in diagnosing adrenal insufficiency including a baseline cortisol, DHEA-S, and an ACTH stimulation test. *
37:54 💭 *Encouragement to consider the three different situations that might arise in a patient - undiagnosed adrenal insufficiency, refractory septic shock, or CIRCI.*
38:22 🛑 *Warning of the potential for iatrogenic adrenal insufficiency in critically ill patients due to drugs like etomidate, azoles, and glucocorticoids.*
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