Crise adrenal

　　1A doença de Addison (hipoatividade adrenal crônica) pode ser desencadeada por situações de estresse como infecções, traumas e cirurgias, ou por interrupção do tratamento hormonal, resultando em redução aguda da função da glândula suprarrenal.

　　2, long-term and large doses of adrenal cortical hormone treatment inhibit the hypothalamus-Pituitary-adrenal axis function, even after discontinuation1years, its function is still low, especially the responsiveness to stress is poor. Oyama's study on the long-term use of steroids in treating14examples before and after anesthesia induction30min and after surgery1h measured blood cortisol levels, respectively, were107±18μg/L (10.7±1.8μg/dl),108±15μg/L (10.8±1.5μg/dl) and148±25μg/L (14.8±2.5μg/dl). The control group10examples are3The blood cortisol levels at108±14μg/L (10.8±1.4μg/dl),175±16μg/L (17.5±1.6μg/dl) and263±18μg/L (26.3±1.8μg/dl). Therefore, patients who have been on long-term corticosteroid therapy may also develop acute adrenal cortical insufficiency if they do not supplement or increase the dose of hormones in response to stress.

　　3After adrenal surgery due to adrenal cortical hyperplasia or adrenal extraneous diseases (such as metastatic breast cancer) dependent on the hypothalamus and pituitary, an adrenal resection is performed; or after the removal of adrenal adenoma, the remaining adrenal glands often atrophy, the hypothalamus-Pituitary-The function of the adrenal axis is suppressed due to the long-term secretion of large amounts of cortisol by the adenoma, and the recovery of its function requires at least9months or1years, if hormones are not supplemented or the dose is not increased in response to stress, it can also cause acute adrenal cortical insufficiency.

　　4, common causes of acute adrenal hemorrhage are severe sepsis, mainly meningococcal sepsis, causing adrenal hemorrhage, and related to disseminated intravascular coagulation. Sepsis caused by other bacteria, epidemic hemorrhagic fever, and other diseases can also lead to adrenal hemorrhage.

　　5, congenital adrenal hyperplasia has been known to have defects in nine enzymes to date, with21hydroxylase,11β-hydroxylase,17α-hydroxylase,18hydroxylase,18oxidase, Δ5-3β-hydroxysteroid dehydrogenase,22carbon chain enzyme,17β-hydroxysteroid dehydrogenase and17,20-cleavage enzyme. Most enzymes are essential for cortisol synthesis. Among them, Δ5-3β-hydroxysteroid dehydrogenase,22Carbon chain enzyme with18Hydroxylase and18Defects in oxidases can also affect the synthesis of mineralocorticoids.

　　Adrenal crisis should be treated immediately once it occurs to avoid life-threatening multiple organ dysfunction. Patients with adrenal crisis have metabolic obstruction in the body, including glucose metabolism obstruction, leading to increased lactic acid production. Once it exceeds the compensatory capacity of the liver, it can directly cause severe metabolic acidosis. At the same time, brain edema can occur due to metabolic disorders in brain tissue, 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 adrenal cortical hormone deficiency, as well as diseases that trigger or cause acute adrenal cortical insufficiency. Adrenal cortical hormone deficiency is often mixed, that is, both glucocorticoids and mineralocorticoids are deficient.

　　1Fever is common, and high fever can reach4Above 0°C, body temperature may sometimes be lower than normal.

　　2Dysgeusia, nausea, vomiting, and other symptoms are often early signs. If identified and treated in time, they often improve quickly, and symptoms such as abdominal pain and diarrhea may also occur.

　　3Neurological weakness, fatigue, apathy, indifference, drowsiness, extreme weakness, can also manifest as irritability, delirium, confusion, and even coma.

　　4Circulatory system heart rate is rapid, up to160 times/min, cold extremities, circulatory collapse, blood pressure drop, collapse into shock, due to the fact that both glucocorticoids and sodium-retaining hormones are lacking in this disease, it is easier and faster to appear peripheral circulatory failure than Sheehan crisis, most patients with changes in consciousness appear simultaneously with blood pressure drop; in a few patients, changes in consciousness occur first, followed by blood pressure drop, we observed that changes in consciousness and blood pressure occur earliest after the cause4h,1/3and2/3patients respectively in24,48h appear.

　　5Symptoms of dehydration are present to varying degrees.

　　Patients with chronic adrenal cortex insufficiency should be educated to consistently take hormones without arbitrary interruption. When encountering stress situations, it is necessary to increase the dose under the guidance of a physician. In case of minor stress such as upper respiratory tract infection, tooth extraction, etc., the dose of hormones should be doubled until the disease is cured, generally4～5days to see control. In case of major stress, such as surgery, myocardial infarction, severe trauma, and infection, hydrocortisone should be administered up to200～300mg/d. The dose of hormones should be increased several hours before surgery. When the patient goes out for treatment, it is necessary to carry enough hormones for use.

　　Total white blood cell count increased, blood concentration and infection caused, neutrophils increased, hemoglobin increased, blood concentration. Hyperkalemia, hyponatremia, hypoglycemia, slight increase in blood urea nitrogen, mild acidosis, and decreased total blood cortisol levels. Adrenaline crisis should be treated immediately upon occurrence to avoid multiple organ dysfunction threatening life.

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

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

　　2What foods should not be eaten during an adrenal crisis

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

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

　　1Supplement with glucocorticoids:If there is loss of consciousness and shock, hydrocortisone sodium succinate ester should be administered immediately100mg dissolved in a small amount of liquid by intravenous injection, this is a water-soluble preparation, with rapid absorption, able to quickly enter the body, and produce immediate and transient improvement in circulatory failure. Subsequently, hydrocortisone (this preparation has low solubility in water, dissolved in50％ethanol solution100mg/20ml, and isotonic saline or5％glucose500ml diluted)100～400mg dissolved in500～2000 ml of liquid for intravenous infusion.

　　2Supplement salt皮质激素：After the use of sodium succinate of hydrocortisone or hydrocortisone, if the systolic blood pressure cannot return to13.3) or if there is hyponatremia, then simultaneous intramuscular injection of acetic acid dehydrocorticosterone (DOCA) can be considered10kPa (1～3mg, daily1～2Also, it can be changed to oral administration when the condition improves and food can be eaten9α-fluorohydrocortisone 0.05～0.2mg/d. Pacientes com redução grave da função adrenal cortical crônica ou com remoção bilateral dos adrenalídeos precisam tomar a dose de manutenção a longo prazo. Durante o uso de hormônios corticosteróides, deve ser observado se há inchaço, hipertensão e hipernatremia e outros efeitos colaterais de superdosagem de medicamentos que retêm sódio e água.

　　3、Corrigir a desidratação e desequilíbrio eletrolítico：Em caso de crise grave de adrenal, a desidratação raramente excede o volume total de líquidos do10％，a estimativa da suplementação da quantidade de líquido é aproximadamente o peso corporal normal do6％ao redor, se o peso70kg, deve ser suplementado com líquido aproximadamente4000ml. A quantidade de fluido a ser administrada deve ser determinada com base na gravidade da desidratação individual, idade e condições cardíacas. A composição do líquido, no início, deve ser dada5％salina glicerinada1000ml, a seguir, conforme necessário, pode ser suplementado com sódio150～250mmol/L. Devido à capacidade diminuída de excreção de carga hídrica dos rins dos pacientes com insuficiência adrenal cortical, a quantidade total e a velocidade da infusão de líquidos devem ser controladas, não podem ser excessivas e rápidas, para evitar a诱发 edema pulmonar. Se houver hiperkaliemia antes do tratamento, após a correção da desidratação e choque, o aumento da urina, a suplementação de hormônios glicocorticoides e glicose, geralmente podem cair para normal, na infusão da3L líquido, pode ser suplementado com potássio conforme necessário.20～40mmol, para suplementar a deficiência geral de potássio. A doença pode ter acidose, mas geralmente não se torna um problema grave, não é necessário suplementar medicamentos alcalinos, quando a capacidade de combinação de dióxido de carbono no sangue for inferior a22Vol％（bicarbonato de sangue <10mmol/L) pode ser suplementado com uma quantidade adequada de bicarbonato de sódio.

　　4、Prevenção e tratamento de hipoglicemia：Embora a doença esteja ausente de cortisol e não esteja associada à redução de hormônios de crescimento, a ocorrência de hipoglicemia não é tão comum quanto a emergência de Sheehan, mas também deve ser notada. Durante o tratamento, é necessário fornecer uma quantidade suficiente de glicose. Se o paciente já estiver em estágio terminal em casa ou em unidade de saúde básica, sem os medicamentos específicos mencionados acima, pode ser administrado imediatamente por via venosa.50％glicose60～100ml, ajuda a prolongar a vida, tempo de resgate urgente, para que seja possível adotar medidas de tratamento específicas.

　　5、Tratar fatores desencadeantes：No caso de infecção concomitante, deve ser escolhido um antibiótico eficaz e adequado, a infecção da incisão deve ser dilatada e drenada, e outros fatores desencadeantes devem ser tratados ativamente durante o período de resgate.

　　No período de perigo da doença, deve ser estabelecida uma enfermagem especial e a enfermagem deve ser fortalecida. Pacientes com insuficiência adrenal cortical são particularmente sensíveis a morfina e drogas barbitúricas, e essas drogas devem ser proibidas antes do início do tratamento específico da emergência.