Med-Surg Endocrine System, part 11: Adrenocortical Insufficiency & Addisonian Crisis

by Cathy Parkes August 01, 2020

Full Transcript

Okay. In this video, we are going to talk about adrenocortical insufficiency, and we're also going to get into our first critical care topic of the endocrine system and talk about an Addisonian crisis. So what is adrenocortical insufficiency? This is where we have insufficient secretion of hormones from the adrenal cortex. These hormones include aldosterone, cortisol, and androgens. So in terms of the pathophysiology behind this disease, we have either primary causes or secondary causes of this disease. With primary causes, we have some kind of injury or infection to the adrenal gland that causes partial or total destruction of the gland. One of the key causes of primary adrenocortical insufficiency is Addison's disease, which is an autoimmune disorder. In terms of secondary causes of adrenocortical insufficiency, this is where we have problem outside of the adrenal gland. One secondary cause is abrupt discontinuation of corticosteroid therapy. Another secondary cause could be an issue with the pituitary gland or the hypothalamus. So if you recall, the hypothalamus produces CRH which causes the pituitary gland to produce ACTH and this allows the adrenal gland to secrete cortisol. So if we have issues with either the hypothalamus or the pituitary gland, then the adrenal gland isn't getting the right message to produce cortisol. So those are secondary causes of adrenocortical insufficiency.

In terms of signs and symptoms, signs and symptoms include weakness, fatigue, weight loss, hypotension, dehydration, hypoglycemia, and a bronzed skin appearance. So it's been reported that JFK, President Kennedy, had Addison's disease, and if you look at pictures of him, he always has this very tan or bronzed appearance, which, apparently, was not from laying out in the sun. It's because he had Addison's disease and this is definitely one of the side effects.

In terms of labs that you will see when someone has adrenocortical insufficiency, you would expect elevated potassium, calcium, and BUN, but you would expect decreased cortisol, sodium, and glucose. So instead of just remembering all these up or down labs, if you think about the hormones involved and which hormones we don't have enough of, you can kind of better understand or think critically about what values will be up and which values will be down. So with this disease, we don't have enough cortisol. And if you recall, cortisol is our stress hormone and it causes elevated levels of glucose. Well, if we don't have enough cortisol, then our glucose levels go down and that's why we have hypoglycemia. Also, with this disorder, we don't have enough aldosterone. And if you recall, aldosterone allows for reabsorption of water and sodium and excretion of potassium. So when we don't have enough aldosterone, we are not reabsorbing all that water and sodium. We're excreting it instead, which is why we end up with hyponatremia as well as hypotension and dehydration, just getting rid of all that water. But we're also retaining all that potassium instead of excreting it. So that's why we end up with hyperkalemia. So it all comes down to really understanding what those hormones are supposed to do, and then you can really understand what to expect when those hormones are not on board.

Right. Now let's now talk about diagnosis of adrenocortical insufficiency. We would use an ACTH stimulation test to help differentiate whether we have primary adrenocortical insufficiency or secondary causes of this disorder. So if a patient has a primary cause of this disorder that means there's a problem with the adrenal gland itself and it's getting sufficient ACTH from the pituitary gland and it doesn't care, like, "You can give me all the ACTH you want. I'm just not going to produce cortisol." So if we give them external ACTH, it doesn't care. He's like, "You can give it to me from the pituitary gland or externally. Either way, I'm kind of injured or damaged and I'm not going to produce cortisol." So we give them the ACTH. If that doesn't make any difference, then we know it is a primary cause of adrenocortical insufficiency. There's a problem with the adrenal gland. However, if we give the patient who has a secondary cause of this disorder ACTH-- so with the secondary cause, remember they're not getting enough ACTH from the pituitary gland. If we give them the ACTH and the adrenal gland's pumped and excited, like, "Finally. I've been waiting for this ACTH and it hasn't been coming. And now I can produce cortisol." So if the adrenal gland suddenly starts producing cortisol like it's supposed to, then we know it was an issue with the pituitary gland or the hypothalamus. It's a secondary cause of this disorder. So that's kind of an explanation of how this ACTH stimulation test works. In terms of treatment, one of the key medications we'll give somebody who has adrenocortical insufficiency is hydrocortisone. We also need to treat that hyperkalemia because if you recall, hyperkalemia is really dangerous and can cause cardiac dysrhythmias. So you really want to bring those potassium levels down. And ways we can do this is-- one medication is called Kayexelate. That helps to bring potassium levels down. You can also give the patient insulin. So insulin helps move potassium into the cells and out of the bloodstream. The only problem is, it also moves glucose into the cells and out of the bloodstream and we have hypogyclemia with this disease. So if we're giving the patient insulin to help bring those potassium levels down in the bloodstream, we also need to give them glucose in order to bring up those glucose levels in the bloodstream. So we're going to give insulin with glucose. We're also going to need to give the patient calcium gluconate to help protect their heart from the detrimental effects of hyperkalemia. In terms of nursing care, we're definitely going to administer our fluids and electrolytes as ordered. We're going to provide food and supplemental glucose to help treat that hypoglycemia. And we're going to teach the patient that in the future, additional corticosteroid doses may be needed during times of illness or stress so that they don't get too low on their cortisol levels.

Alright. Now let's talk about an Addisonian crisis. So if you're following along with cards, I'm on Card 29 in the endocrine system. An Addisonian crisis is where we have a life-threatening disorder caused by adrenal insufficiency. And causes of this crisis can include infection, stress, trauma, or abrupt discontinuation of corticosteroids. In terms of the signs and symptoms, a lot of them are going to be fairly similar to what we just talked about. So weakness, fatigue, that type of thing. But we're also going to have severe hypotension that can cause shock. And then, we also may have dysrhythmias because we have very elevated levels of potassium. So in terms of treatment, we're definitely going to give this patient IV glucocorticoids as well as fluids with dextrose. And we need to really identify and treat the underlying cause of this crisis. So if the patient has infection or some kind of trauma, we need to try to address that. In terms of nursing care, we're going to want to closely monitor this patient's vital signs, their eyes and nose, and their weight. And monitor for signs of shock. So some of the key signs of shock include decreased level of consciousness and decreased urine output. So urine output that drops below 30 ml per hour. We're also going to want to closely monitor for dysrhythmias because of that hyperkalemia and provide the patient with bed rest and a quiet environment. So that is it for this video. When we pick it up in my next video, we will talk about Cushing's Disease. Thanks so much for watching. And if you've enjoyed this content, be sure to like this video and leave us a comment with any suggestions you have for future content!


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