An elderly diabetic woman with chronic steroid-dependent bronchospasm has an ileocolectomy for a perforated cecum. She is taken to the ICU intubated and is maintained on broad-spectrum antibiotics, renal dose dopamine, and a rapid steroid taper. On postoperative day 2, she develops a fever of 39.2degC (102.5degF), hypotension, lethargy, and laboratory values remarkable for hypoglycemia and hyperkalemia. Which of the following is the most likely explanation for her deterioration?
Acute adrenal insufficiency can occur in patients with severe stress, infection, or trauma or as a result of abrupt cessation or too rapid tapering of chronic glucocoicoid therapy, and is classically manifested as changing mental status, increased temperature, cardiovascular collapse, hypoglycemia, and hyperkalemia. The diagnosis can be difficult to make and requires a high index of suspicion. Its clinical presentation is similar to that of sepsis; however, sepsis is generally associated with hyperglycemia and no significant change in potassium. The treatment for adrenal crisis is intravenous steroids, volume resuscitation, and other suppoive measures to treat any new or ongoing stress. Dexamethasone should be used as steroid replacement when additional testing with an adrenocoicotropic hormone (ACTH) stimulation test is planned, since hydrocoisone can interfere with measurement of coisol levels. Steroid treatment can be subsequently conveed to oral medication and tapered after treatment of the adrenal crisis
Sepsis
Hypovolemia
Adrenal insufficiency
Acute tubular necrosis
Preoperative assessment and monitoring in anaesthesia