NHS FORTH VALLEY Adult Adrenal Insufficiency Management Guidelines

Transcription

1 NHS FORTH VALLEY Adult Adrenal Insufficiency Management Guidelines Date of First Issue 01 August 2006 Approved 01 August 2006 Current Issue Date 30 th May 2014 Review Date 1 st July 2018 Version 1.2 EQIA Yes 01/08/2010 Author / Contact Group Committee Final Approval Dr Linda Buchanan Diabetes Consultant Group This document can, on request, be made available in alternative formats Version th May 2014 Page 1 of 10

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Linda Buchanan, John Doig, Chris Kelly, Alison Mackenzie Nick Barwell. Consultation Process: Reviewed at Diabetes Consultant Meeting and Diabetes Clinical Governance Meeting. Distribution: Acute medical wards NHS FV Quality Improvement Website Change Record Date Author Change Version 01/10/2010 LMB Removed clinical support nurse from box page /07/12 LMB Removed Norman Peden as author and added Nick Barwell 26/07/12 LMB Added line about Endcorine COW bottom of page 3 26/07/12 LMB In first box page 4 changed pre-assessment to pre-operative assessment clinic Version th May 2014 Page 2 of 10

3 NHS Forth Valley Adult Adrenal Insufficiency Management Guidelines Adrenal insufficiency results from inadequate adrenocortical function and may be due to Addisons Disease, previous bilateral adrenalectomy, pituitary disorders, hypothalmic dysfunction or sudden withdrawal of long term oral steroids in people with chronic disease e.g. asthma. Adrenal insufficiency may be precipitated by acute infections e.g. septicaemia, haemorrhage, trauma or any acute medical / surgical condition. Although rare, it can result in life threatening adrenal crisis and requires replacement steroid therapy for life. During periods of stress, illness, surgery, anaesthesia or trauma, the amount of steroid required by the body increases and an appropriate dose adjustment is required (Coursin 2002). When the patient is unable to eat or drink (or is vomiting), an alternative route of administration must be used. The following points should be considered when managing the patients care: Patients who take 10mg or less of prednisolone daily should not require perioperative steroids greater than their usual requirements, (Nicholson et al 1998). In patients undergoing minor surgery, consideration should be given to increasing ongoing therapy only. In patients undergoing moderate or major surgery, please follow the attached guidelines. Patients who have not received steroids for more than three months are considered to have full recovery of the hypothalmic pituitary adrenal axis (HPA) and do not normally require steroid cover for procedures, (Nicholson et al 1998). The following guidelines provide information on management of the patient with adrenal insufficiency. Please seek appropriate specialist advice from anaesthetists or physicians for specific issues of patient management. NB. These guideline differ form the Sepsis Guidelines used in Intensive Care Areas. Please inform the endocrine consultant of the week on bleep 1965 if a patient presents with an adrenal crisis. Version th May 2014 Page 3 of 10

4 ELECTIVE PATIENT MANAGEMENT GUIDELINES Steroids must not be withheld if the patient is nil by mouth as lack of adrenal response may cause acute cardiovascular collapse, hypotension and shock that can become irreversible. At the pre-op assessment clinic the documentation should record if the patient is on the following medication: 1. Takes oral steroids regardless of dose 2. Uses high dose inhaled steroids e.g. fluticasone >1mg daily, mometasone > 800microgms daily, beclomethasone or budesonide>2mg daily 3. Has used oral or high dose inhaled steroids within the previous three months? The anaesthetist should only be informed if in your professional opinion there is concern regarding the patient s management. ELECTIVE PRE- OPERATIVE MANAGEMENT Highlight in the patient s clinical assessment (Pharmacist ) the potential need to use parenteral steroids peri-operatively. Oral / inhaled dose of steroids should be administered as normal up to and including the morning of theatre. An increased oral dose of steroids or administering intravenous hydrocortisone 50 mgs (bolus) will be prescribed perioperatively. Version th May 2014 Page 4 of 10

5 EMERGENCY PATIENT MANAGEMENT GUIDELINES Patients admitted on oral or high dose inhaled steroids may require steroids at an increased dose. EMERGENCY ADMISSION (Medical or Surgical) If the patient is nil by mouth, ensure parenteral steroids are prescribed and administered as an alternative to oral steroids. The dose will be dependent on the patient s clinical condition and the doctor will make the decision. If surgery is planned ensure the anaesthetist is aware the patient takes oral or high dose inhaled steroids. Steroids must not be withheld if the patient is nil by mouth as lack of adrenal response may cause acute cardiovascular collapse, hypotension and shock that can become irreversible Version th May 2014 Page 5 of 10

6 MANAGEMENT OF LONG TERM STEROID REPLACEMENT NEEDS Give regular dose by an alternative route if necessary Increase dose to cover stress response, Depending on type of surgery Minor/Moderate Surgery Major Surgery Patients normal oral/inhaled dose administered pre operatively and I V hydrocortisone 50 mgs on induction or with pre med should be administered. Administer 50 mgs hydrocortisone IV in 24 hours either as 50mg od or 25mg bd. When able to eat and drink normally, resume normal therapy. If unable to eat/drink or is vomiting continue with IV dose at 50mg/day as before. Based on Nicholson et al (1998). Patients normal oral/inhaled dose steroid administered pre operatively and I V hydrocortisone 50mgs on induction or with pre med. Administer 100mgs IV hydrocortisone, by infusion, in 24 hours as either 100mgs od or 50mgs bd until the oral route is appropriate. Omit oral/inhaled dose. If eating/drinking and no vomiting commence normal oral dose. If remain unable to take diet and fluids after three days, continue with the IV dose. Cortisol levels normally return to baseline hours after surgery but may take up to 72 hours (Shaw 2002) Version th May 2014 Page 6 of 10

7 EMERGENCY MANAGEMENT OF ADRENAL INSUFFICIENCY (MEDICAL OR SURGICAL PATIENT) Clinical Features Anorexia, nausea, vomiting Craving for salt Headaches Memory loss Postural hypotension Tachycardia Abdominal pain Shock Unexplained pyrexia This is life threatening treat the patient rather than wait for confirmation of the problem. The following three steps must be implemented (Krasner 1999 Turner and Wass 2003) Step One Take blood for urea, electrolytes, glucose and cortisol. Refer to appendix one for acceptable ranges Step Two Commence an IV infusion of 0.9% saline (to reverse fluid and sodium deficiency). Correct hypoglycaemia Step Three 100mg IV hydrocortisone bolus should be administered immediately followed by 100mgs of IV hydrocortisone six hourly for hours or until oral therapy can commence. Version th May 2014 Page 7 of 10

8 Appendix One Acceptable Blood Ranges Substance Potassium Sodium Calcium Urea Creatinine Glucose (fasting) Cortisol - am Cortisol - midnight Acceptable blood range mmol/litre mmol/litre mmol/litre mmol/litre micromols/litre mmol/litre nanomol/litre nanomol/litre Version th May 2014 Page 8 of 10

9 REFERENCES Cooper M Stewart P (2003) Current Concepts: Corticosteroid Insufficiency in Acutely Ill Patients The New England Journal of Medicine 348 (8) Coursin D Wood K (2002) Corticosteroid Supplementation for Adrenal Insufficiency American Medical Association Krasner AS (1999) Glucocorticoid Induced Adrenal Insufficiency JAMA Nicholson G Burrin JM Hall GM (1998) Peri operative Steroid Supplementation Anaesthesia 53 (11) Shaw M (2002) When is Perioperative Steroid Coverage Necessary? Cleveland Clinic Journal of Medicine 69 (1) 9-11 Turner H Wass J (2003) Oxford Handbook of Endocrinology and Diabetes Oxford University Press FURTHER READING Arlt W Allolio B (2003) Adrenal Insufficiency Lancet Nicholson G Burrin JM Hall GM (1998) Perioperative Steroid Supplementation Anaesthesia Offner PJ Moore E Ciesla D Hoyt D Moore F Peterson S (2002) The Adrenal Response after Severe Trauma American Journal of Surgery 184 (6) Salem M Tainsh RE JR Bromberg J Loriaux DL Chernow B (1994) Perioperative Glucocorticoid Coverage A Reassessment 42 years after Emergence of a problem Ann Surg Yalamarthi S (2002) Perioperative Steroids in Surgical Patients Royal College of Surgeons Surgical Skills and Knowledge Website Royal College of Surgeons Edinburgh Version th May 2014 Page 9 of 10

10 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - fv-uhb.nhsfv-alternativeformats@nhs.net Version th May 2014 Page 10 of 10