Adrenal crisis

　　1, Chronic adrenal cortical insufficiency (Addison's disease) is induced by stress situations such as infection, trauma, and surgery, or by acute reduction of adrenal cortical function due to discontinuation of hormone medication.

　　2, Long-term and large doses of adrenal cortical hormone therapy suppress the function of the hypothalamus-pituitary-adrenal axis, even after stopping the drug for 1 year, its function remains low, especially poor responsiveness to stress. In the study by Oyama, 14 patients with long-term steroid treatment had blood cortisol levels measured before anesthesia induction, 30 minutes after induction, and 1 hour after surgery, which were 107±18μg/L (10.7±1.8μg/dl), 108±15μg/L (10.8±1.5μg/dl), and 148±25μg/L (14.8±2.5μg/dl), respectively. While in the control group of 10 patients, the blood cortisol levels at these three times were 108±14μg/L (10.8±1.4μg/dl), 175±16μg/L (17.5±1.6μg/dl), and 263±18μg/L (26.3±1.8μg/dl), respectively. Therefore, patients who have long-term corticosteroid therapy may also develop acute adrenal cortical insufficiency when faced with stress if the hormone dose is not supplemented or increased in time.

　　3. Adrenalectomy is performed due to adrenal cortical hyperplasia dependent on the hypothalamus and pituitary, or adrenal diseases outside the adrenal glands (such as metastatic breast cancer). Or after the removal of adrenal adenomas, the remaining adrenal glands often atrophy. The function of the hypothalamus-pituitary-adrenal axis is suppressed due to the long-term secretion of large amounts of cortisol by the adenoma. The recovery of its function requires at least 9 months or more than 1 year. Without hormone supplementation or an increase in hormone dose under stress conditions, it can also cause acute adrenal cortical insufficiency.

　　4. Acute adrenal hemorrhage is commonly seen in severe sepsis, mainly meningococcal sepsis, which causes adrenal hemorrhage and is related to disseminated intravascular coagulation. Adrenal hemorrhage can also occur concurrently with sepsis caused by other bacteria, epidemic hemorrhagic fever, and other diseases.

　　5. Up to now, there are nine types of enzyme defects in congenital adrenal hyperplasia, including 21-hydroxylase, 11β-hydroxylase, 17α-hydroxylase, 18-hydroxylase, 18-oxidase, Δ5-3β-hydroxysteroid dehydrogenase, 22-carbon chain enzyme, 17β-hydroxysteroid dehydrogenase, and 17,20 lyase. Most of these enzymes are essential for cortisol synthesis. Defects in Δ5-3β-hydroxysteroid dehydrogenase, 22-carbon chain enzyme, and 18-hydroxylase and 18-oxidase can also affect the synthesis of sodium-retaining hormones.

　　Once an adrenal crisis occurs, immediate treatment should be provided to avoid life-threatening multiple organ dysfunction. Patients with adrenal crisis have metabolic disorders, including impaired glucose metabolism, leading to increased lactic acid production. When this exceeds the liver's compensatory capacity, it can directly cause severe metabolic acidosis. At the same time, metabolic disorders in brain tissue can cause brain edema, even triggering a cerebral hernia. Therefore, patients with consciousness disorders should be vigilant about the occurrence of this disease.

　　The clinical manifestations of adrenal crisis include symptoms caused by the lack of adrenal cortical hormones, as well as the manifestations of diseases that trigger or cause acute adrenal cortical insufficiency. The lack of adrenal cortical hormones is mostly mixed, that is, both glucocorticoids and sodium-retaining hormones are lacking.

　　1. Fever is common, with high fever up to 40℃ or above, and sometimes the body temperature can be lower than normal.

　　2. Early symptoms often include anorexia, nausea, vomiting, and abdominal pain, diarrhea, and other symptoms, which can usually improve quickly if timely identified and treated.

　　3. The nervous system is weak, listless, apathetic, indifferent, drowsy, and in a state of extreme weakness. It can also manifest as restlessness, delirium, confusion, and even coma.

　　4. The heart rate in the circulatory system is rapid, reaching up to 160 times/min, with cold extremities, circulatory collapse, blood pressure drop, and shock. Due to the lack of both glucocorticoid and sodium-retaining hormones in this disease, it is easier and faster to develop peripheral circulatory failure than in Sheehan's crisis. The change in consciousness of most patients occurs simultaneously with the drop in blood pressure; in a few patients, the change in consciousness occurs first, followed by the drop in blood pressure. We observed that the change in consciousness and blood pressure occurred as early as 4 hours after the triggering factor, with 1/3 and 2/3 of the patients showing symptoms within 24 and 48 hours, respectively.

　　5. Dehydration signs are often present to varying degrees.

　　Patients with chronic adrenal cortical insufficiency should be educated to persist in taking hormones and not to arbitrarily discontinue. When encountering stressful situations, the dose must be increased under the guidance of a physician. In case of minor stress, such as upper respiratory tract infection, tooth extraction, etc., the hormone dose should be doubled until the disease is cured, usually within 4-5 days. In case of major stress, such as surgery, myocardial infarction, severe trauma, and infection, hydrocortisone should be given at 200-300 mg/d. The hormone dose should be increased several hours before surgery. When the patient goes out, he must carry enough hormones for use.

　　Increased total white blood cell count, blood concentration, and infection caused by neutrophils增多, increased hemoglobin, blood concentration. Hyperkalemia, hyponatremia, hypoglycemia, slightly increased blood urea nitrogen, mild acidosis, and decreased total cortisol in blood. Once an adrenaline crisis occurs, treatment should be immediate to avoid the risk of life-threatening multiple organ dysfunction.

　　1. What foods are good for the body during adrenal crisis

　　Eat more vegetables and soy products, and eat low-salt, high-vitamin, light, and fresh foods.

　　2. What foods should not be eaten during adrenal crisis

　　Fish, shrimp, seafood, rooster, crucian carp, and beef.

　　(The above information is for reference only, please consult a doctor for details)

　　1. Supplement glucocorticoids:If there is confusion and shock, 100 mg of hydrocortisone sodium succinate ester should be dissolved in a small amount of liquid and administered intravenously. This is a water-soluble preparation, which is absorbed quickly and can quickly enter the body to produce immediate and short-term improvement in circulatory failure. Subsequently, 100-400 mg of hydrocortisone (this preparation has a low solubility in water, dissolved in 50% ethanol solution 100 mg/20 ml, diluted with isotonic saline or 5% glucose 500 ml when used) is dissolved in 500-2000 ml of liquid for intravenous infusion.

　　2. Supplement salt corticosteroids:After using hydrocortisone sodium succinate ester or hydrocortisone, if the systolic blood pressure cannot recover to 13.3 kPa (100 mmHg) or if there is hyponatremia, acetic acid deoxy皮质酮 (DOCA) 1-3 mg can be simultaneously injected intramuscularly, once or twice a day, or 9α-fluorohydrocortisone 0.05-0.2 mg/d can be taken orally when the condition improves and food can be ingested. Patients with severe chronic adrenal cortical insufficiency or bilateral adrenal gland resection require long-term maintenance dosage. During the use of salt corticosteroids, attention should be paid to the side effects of sodium and water retention, such as edema, hypertension, and hypernatremia due to drug overdose.

　　3. Correcting Dehydration and Electrolyte Imbalance:During severe adrenal crisis, dehydration rarely exceeds 10% of the total body fluid. The estimated fluid volume to be supplemented is about 6% of the normal body weight, such as a weight of 70kg, about 4000ml of fluid should be supplemented. The amount of fluid replacement also needs to be determined according to the degree of dehydration, age, and heart condition of the individual. The composition of the infusion, initially 1000ml of 5% glucose saline, and then adjusted according to circumstances, can supplement sodium 150-250mmol/L. Due to the reduced ability of patients with adrenal cortical insufficiency to excrete water load, the total amount and speed of fluid infusion need to be controlled, and should not be excessive or too fast to prevent the induction of pulmonary edema. If there is hyperkalemia before treatment, it can generally be reduced to normal after correcting dehydration and shock, increasing urine output, supplementing glucocorticoids and glucose. When the blood bicarbonate binding power is below 22Vol% (blood bicarbonate < 10mmol/L), appropriate bicarbonate sodium can be supplemented.

　　4. Prevention and Treatment of Hypoglycemia:Although this disease only lacks cortisol and does not have a simultaneous decrease in growth hormone, the occurrence of hypoglycemia is not as common as in Sheehan's crisis. However, attention should be paid to providing sufficient glucose during treatment. If the patient is in the terminal stage at home or in a primary healthcare unit and lacks the above specific drugs, 50% glucose 60-100ml can be injected intravenously immediately, which helps to extend life, urgent time, and make it possible to take specific treatment measures.

　　5. Treating Triggers:When complicated with infection, effective and appropriate antibiotics should be used. Incision infection requires debridement and drainage. During the rescue period, other triggering factors should also be actively treated.

　　During the critical period of illness, special care should be provided and nursing care should be strengthened. Patients with adrenal cortical insufficiency are particularly sensitive to morphine and barbiturate drugs. These drugs should be prohibited before the start of specific treatment for crises.