Safety considerations in patients with adrenal insufficienc

Endocrinology

1. Critique the national patient safety alert relating to steroid emergency cards and adrenal crisis in adults 2. Identify who is at risk of an adrenal crisis 3. Apply national guidance and best practice recommendations when assessing and treating patients who are at risk of, or suffering from, an adrenal crisis

What are the learning outcomes for safety considerations in adrenal suppression? (3 points)

1. The NRLS identified 320 patient safety incidents between July 2018 and July 2020 2. Four deaths occurred 3. Four patients required admission to critical care 4. Incidents related to adrenal crisis and poor management of steroid-dependent patients

What patient safety incidents were identified in the NRLS report? (4 points)

1. Failure to implement, or inadequate, peri-operative management 2. Inadequate admission and discharge medicines reconciliation 3. Prescribing errors on admission, especially usual steroids not prescribed 4. Omitted or delayed administration of prescribed steroid doses, including ward stock unavailability and alternative administration route issues 5. Delayed or absent recognition and treatment of adrenal crisis by emergency services and emergency departments 6. Inappropriate 999/111 response causing treatment delays

What themes were identified across adrenal crisis patient safety incidents? (6 points)

1. A real patient with adrenal insufficiency was admitted after a fall at home causing a fractured shaft of femur 2. She was normally on steroid replacement with hydrocortisone after a pituitary tumour had been resected 40 years earlier 3. No steroids were given for the first two days of admission due to an inadequate drug history 4. Two days into admission she started vomiting and aspirated 5. She then suffered a cardiac arrest and died

What happened in the adrenal insufficiency case study? (5 points)

1. Any patient with diagnosed adrenal insufficiency 2. Patients taking exogenous glucocorticoid therapy at physiological or supraphysiological doses for more than 4 weeks 3. Risk examples include prednisolone 5 mg/day or dexamethasone 500 micrograms/day

Who is clearly at risk of adrenal crisis? (3 points)

1. Patients taking short courses of steroids for more than 1 week at prednisolone doses above 40 mg/day who have also been on long-term steroids within the last year 2. Patients with a regular need for repeated steroid courses 3. Patients receiving repeated doses of parenteral steroids 4. Patients on high-dose inhaled steroids equivalent to more than 1000 micrograms/day budesonide 5. Patients on high-dose inhaled steroids equivalent to more than 800 micrograms/day budesonide if also using nasal steroids 6. Patients using large quantities of potent or very potent topical steroids, such as 200 g or more per week, or potent topical steroids plus significant amounts of other glucocorticoids

Which other steroid users may theoretically be at risk of adrenal crisis? (6 points)

1. Omission of steroids in adrenal insufficiency or steroid dependence can lead to adrenal crisis and death 2. Risk is especially high during physiological stress such as intercurrent illness or surgery 3. Higher steroid doses are required during acute illness or major body stressors to prevent adrenal crisis

Why can omission of steroids cause adrenal crisis? (3 points)

1. Fatigue, weakness and feeling terrible 2. Low blood pressure, postural dizziness or hypotension, dizziness, collapse and severe hypovolaemic shock 3. Abdominal pain, tenderness and guarding, nausea and vomiting, especially in primary adrenal insufficiency, plus history of weight loss 4. Feeling very cold with uncontrollable shaking 5. Abdominal pain, back pain, limb pain, cramps or spasms, which can be distracting 6. Headache, confusion, drowsiness and loss of consciousness 7. Symptoms may be non-specific, so adrenal crisis must be recognised quickly in at-risk patients

What are the clinical signs and symptoms of adrenal crisis? (7 points)

1. Hyponatraemia can occur in primary and secondary adrenal insufficiency 2. Hyperkalaemia can occur in primary adrenal insufficiency 3. Pre-renal AKI may occur, shown by increased serum creatinine due to hypovolaemia

What laboratory findings may occur in adrenal crisis? (3 points)

1. Patients thought to be having an adrenal crisis should be treated promptly 2. Give immediate hydrocortisone 100 mg by IV or IM injection 3. Continue with hydrocortisone 50–100 mg every 6 hours/QDS or 200 mg over 24 hours by continuous IV infusion 4. Give rapid rehydration with sodium chloride 0.9%, using a 500 mL bolus over 15 minutes followed by 3–4 L over 24 hours 5. Emergency treatment should not be delayed while waiting to confirm adrenal insufficiency

How should suspected adrenal crisis be managed urgently? (5 points)

1. All healthcare professionals should know which patient groups are at risk of adrenal crisis 2. They should understand the need to start treatment promptly because delay can be fatal

What should healthcare professionals know about adrenal crisis emergency treatment? (2 points)

1. Give IV hydrocortisone 100 mg on induction 2. Follow with hydrocortisone 200 mg over 24 hours by continuous infusion or 50 mg QDS 3. Post-operatively, give IV hydrocortisone 200 mg over 24 hours while nil by mouth, then resume usual hydrocortisone if recovery is uncomplicated or double dose for up to 7 days if not

How should patients with primary adrenal insufficiency/Addison’s disease be managed for surgery under anaesthesia? (3 points)

1. Consider IV fluids and IV or IM hydrocortisone 50 mg every 6 hours/QDS during preparation, especially for fludrocortisone-dependent patients 2. Give IV or IM hydrocortisone 100 mg at the start of the procedure 3. Resume enteral double hydrocortisone doses for 24–48 hours after the procedure

How should patients with primary adrenal insufficiency/Addison’s disease be managed for bowel procedures requiring laxatives or enema? (3 points)

1. For labour and vaginal delivery, give IV hydrocortisone 100 mg at onset of labour 2. Continue hydrocortisone 200 mg over 24 hours by continuous infusion or 50 mg QDS 3. Resume enteral double hydrocortisone doses for 48 hours after delivery 4. For minor surgery, take an extra dose 60 minutes before and another extra dose 60 minutes after

How should patients with primary adrenal insufficiency/Addison’s disease be managed for labour, vaginal delivery and minor surgery? (4 points)

1. Give IV hydrocortisone 100 mg on induction 2. Follow with hydrocortisone 200 mg over 24 hours by continuous infusion or 50 mg QDS 3. Post-operatively, give IV hydrocortisone 200 mg over 24 hours while nil by mouth, then resume usual steroid if recovery is uncomplicated or double dose for 48 hours if not

How should patients with tertiary adrenal insufficiency be managed for surgery under anaesthesia? (3 points)

1. Consider IV fluids and IV or IM hydrocortisone 50 mg every 6 hours/QDS during preparation, especially for fludrocortisone-dependent patients 2. Give IV or IM hydrocortisone 100 mg at the start of the procedure 3. Resume enteral double steroid doses for 24–48 hours after the procedure

How should patients with tertiary adrenal insufficiency be managed for bowel procedures requiring laxatives or enema? (3 points)

1. For labour and vaginal delivery, give IV hydrocortisone 100 mg at onset of labour 2. Continue hydrocortisone 200 mg over 24 hours by continuous infusion or 50 mg QDS 3. Resume enteral double steroid doses for 48 hours after delivery 4. For minor surgery, take an extra dose 60 minutes before and another extra dose 60 minutes after

How should patients with tertiary adrenal insufficiency be managed for labour, vaginal delivery and minor surgery? (4 points)

1. Explain the need for lifelong replacement therapy 2. Explain the life-threatening complications linked to inadequate glucocorticoid replacement 3. Teach patients how to recognise symptoms of adrenal crisis and manage them appropriately 4. Explain the importance of making sure their medical team knows they have adrenal insufficiency 5. Advise the patient to carry an alert card such as a MedicAlert or steroid treatment card 6. Teach sick day rules, especially for febrile illness

What patient information and self-care advice should be given after adrenal insufficiency diagnosis? (6 points)

1. Sick day rules apply if unwell with fever of 38°C, bad cold, flu, diarrhoea, infection or significant injury 2. Double usual hydrocortisone dose to a minimum of 40 mg/day 3. If using modified-release hydrocortisone, temporarily switch to standard-release tablets at high dose 4. If vomiting occurs within 30 minutes of a dose, repeat a double dose 5. Seek specialist advice if diarrhoea occurs 6. 100 mg IM hydrocortisone may be necessary 7. For strenuous exercise, patients may need to double hydrocortisone and fludrocortisone and increase fluid intake

What are the sick day rules for hydrocortisone during illness or injury? (7 points)

1. If on prednisolone, increase dose to at least 10 mg/day and consider splitting the dose 2. If taking prednisolone 3–10 mg/day, minimum unwell dose is 5 mg twice daily, but consider increasing to 15–20 mg 3. If taking prednisolone 10 mg/day or more, split to twice daily and consider increasing to 15–20 mg 4. If on other steroids, give 20 mg hydrocortisone stat then 10 mg QDS 5. For less strenuous exercise, patients may need an additional 5–10 mg hydrocortisone before starting

What are the sick day rules for prednisolone, other steroids and exercise? (5 points)

1. Patients taking Plenadren should switch to regular immediate-release hydrocortisone 2. The suggested immediate-release hydrocortisone dose is 10 mg every 6 hours 3. Patients on Efmody can either switch to standard release at double dose or continue Efmody and add standard-release hydrocortisone to reach a double dose 4. If hydrocortisone has increased to 50 mg/day or more, stop fludrocortisone and restart it once tapering back down

How should modified-release hydrocortisone and fludrocortisone be managed during sick days? (4 points)

1. Critique the national patient safety alert relating to steroid emergency cards and adrenal crisis in adults 2. Identify who is at risk of adrenal crisis 3. Apply national guidance and best practice recommendations when assessing and treating patients at risk of, or suffering from, adrenal crisis

What learning outcomes are reviewed at the end of the adrenal suppression safety lecture? (3 points)

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