Intra-operative crises18 / 21
Adrenal crisis in Addison's disease at appendicectomy52-year-old woman, 64 kg, Addison's disease on hydrocortisone 20 mg morning and 10 mg evening
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Know this first
- Primary adrenal failure loses both glucocorticoid and mineralocorticoid.
- Adrenal crisis: distributive shock, vomiting, hypoglycaemia, hyperkalaemia, hyponatraemia.
- Hydrocortisone 100 mg IV bolus, then 100 mg every 6 hours for 24 hours.
- Dexamethasone has no mineralocorticoid effect; etomidate is avoided.
- Hypoglycaemia: dextrose 25 g IV (50 mL of 50%).
The patient
52-year-old woman, 64 kg, Addison's disease on hydrocortisone 20 mg morning and 10 mg evening, plus fludrocortisone.
Vomiting for 24 hours; she has kept no tablets down.
Urgent laparoscopic appendicectomy tonight.
Vitals: BP 98/58, HR 108, SpO2 98% on air, temperature 38.1 °C. Na+ 131 mmol/L, K+ 5.4 mmol/L, glucose 4.1 mmol/L.
The examiner asks
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Consider
What are your concerns?
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- A 52-year-old with Addison's disease, vomiting for a day, for urgent laparoscopic appendicectomy. Patient
- Primary adrenal failure: without her tablets she has neither cortisol nor aldosterone. Disease
- A day of vomiting means her doses are lost: she is heading for crisis. Stem trigger
- Low sodium, high potassium and borderline glucose already point to adrenal insufficiency. Disease
- Appendicitis adds fever and surgical stress on top of missed steroid. Surgery
Prepare
How will you prepare her?
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- Hydrocortisone 100 mg IV now, before induction; her oral cover has failed. (Disease)
- Then 100 mg IV every 6 hours for 24 hours.
- Isotonic crystalloid before induction; glucose and electrolytes rechecked.
- No etomidate; a reduced, titrated dose with a vasopressor running.
- Never dexamethasone alone for her: it has no mineralocorticoid action.
Crisis
Theatre called her before any hydrocortisone was given. Thirty minutes into surgery, BP is 68/36 despite 2 L of crystalloid and noradrenaline at 0.3 mcg/kg/min. What do you do?
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- Shock resistant to fluid and pressor in Addison's without steroid: adrenal crisis until proven otherwise. Crisis
- Hydrocortisone 100 mg IV now; it carries mineralocorticoid activity too.
- More isotonic fluid and vasopressors meanwhile; noradrenaline alone won't fix this.
- Glucose and potassium now; ECG watched for hyperkalaemia.
- Exclude bleeding, sepsis from the appendix, anaphylaxis and too much anaesthetic.
- Surgeon asked to finish quickly; arterial line placed. Surgery
Crisis
In recovery she is drowsy; glucose 2.6 mmol/L, Na+ 126 mmol/L, BP 92/54. What now?
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- Hypoglycaemia: dextrose 25 g IV, 50 mL of 50%, then glucose rechecked. Crisis
- Drowsy and hypoglycaemic: I watch her airway closely until she wakes. Airway
- Low sodium from lost aldosterone and vomiting: isotonic saline; rise kept under 8–10 mmol/L in 24 hours. Crisis
- Hydrocortisone continues at 100 mg every 6 hours.
- HDU; taper back to her usual dose over the next 1–2 days as she recovers. After surgery
- Endocrine team reviews her plan for vomiting before she goes home.
Fatal mistakes
- No steroid cover in a patient on replacement.
- Escalating vasopressors without hydrocortisone.
- Missing her hypoglycaemia.
- Etomidate for induction.
Checked against: Miller 10e · Barash 9e
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