Adrenal insufficiency may be related to adrenal gland replacement by metastatic tumors or to adrenocortical suppression by therapeutic glucocorticoid administration. In either case, maximal adrenal function may be inadequate to support the individual when stressed by infection, dehydration, surgery, or trauma. Adrenal crisis and shock with vasomotor collapse may be sudden and fatal. The differential diagnosis of cancer patients with fever, dehydration, hypotension, and shock would more frequently include sepsis and hemorrhagic shock. Adrenal crisis is less common than bleeding and sepsis, but the steroid-dependent patient should be empirically given intravenous steroids with both glucocorticoid and mineralocorticoid effect.
Laboratory clues to the possible concomitant presence of adrenal insufficiency may be mild hypoglycemia, hyponatremia, hyperkalemia, and eosinophilia. Azotemia is, however, nonspecific and is often present in dehydration from any cause. In suspected cases, a serum cortisol should be drawn prior to steroid treatment.
Normal adrenal glands maximally produce approximately 300 mg per day of hydrocortisone when stressed. This has served as a guideline for replacement therapy. Adrenalectomized individuals are maintained on average doses of 35 to 40 mg of hydrocortisone per day, and this is increased during potential stress. Appropriate emergency doses of hydrocortisone hemisuccinate (Solucortef) would be 250 to 500 mg intravenously.
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