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 🚂 *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.* Made with HARPA AI

[@EndocrinologyIndia]

🎯 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.* Made with HARPA AIMakl