Hx: (1º) n/v, diarrhea, fatigue, hypotension/syncope, hyperpigmentation,
hypoNa, hyperK;
(2º) -
Etiology: Causes:
autoimmune, infectious (Tb, histoplasmosis, ; in (in HIV):
CMV, MAI), Waterhouse-Friderichsen, cancer (breast, lung, lymphoma), drugs
(ketoconazole)
Dx: -
Studies: AM cortisol: <5 insufficient, 5-18 indeterminant,
>18 sufficient
If indeterminant --> Low dose cosyntropin stimulation test. Check baseline & 30 min cortisol level
after administering cosyntropin 1 mcg IV.
A cortisol value of > 18 mcg/dLl pre-stim or
after 30 min rules-out adrenal insufficiency (sensitivity 95%, specificity
96%).
- Relative
adrenal insufficiency in sepsis --: High
dose cosyntropin stimulation. Check baseline, 30 min & 60 min cortisol
level after administering co, co-syntropin 250mcg IV. Relative
insufficiency ≤ 9 mcg/dl increase at either 30 or 60 min. Rx: hydrocortisone 100mg IV q6hrs &
fludrocortisone 50mcg IV qd x 7d. [JAMA (2002) 228: 862 – 71]
Diabetic Ketoacidosis
Hx: delta MS, n/v, abd pain, polyuria,
polydipsia, dehydration, ketotic breath, tachycardia, hypotension
Etiology:
infection, medicine non-compliance, CVA, MI, severe illness, surgery, pregnancy
Dx:
hyperglycemia >300mg/dl, anion gap metabolic acidosis, hypo-PO4, hypo-Mg,
pseudohyponatremia, hypo-K or hyper-K, pre-renal ARF, hemoconcentration, elev
WBCs.
Rx:
replete fluid, lytes, insulin and follow closely. Use NS at rate>125cc/hr,
change to D5 NS when dexi<250. Give insulin 10units IV stat, then
0.1-0.2U/kg/hr and titrate to AG and dexis. Glucose should decrease 80/hr. Keep
insulin drip going until gap is closed and bicarb is >18. Give SC insulin
with closed gap and turn off insulin drip one hour later. Follow dexi q1hr,
BMP/Mg/PO4 q2-4hr. Replete K, Mg, PO4. Only use IV bicarbonate if pH<7.0 or
severe hyperkalemia. Monitor for arrhythmias, shock, hypoglycemia.