Volume 189 - Issue 6
Management of adrenal insufficiency during the stress of medical illness and surgery
Author: Ian J Woodforth
Med J Aust 2008; 189 (6): 350-351. || doi: 10.5694/j.1326-5377.2008.tb02069.x
Published online: 15 September 2008
Published online: 15 September 2008
To the Editor: In their recent “Clinical Update” on adrenal insufficiency, Jung and Inder1 state:
In patients with adrenal insufficiency who are fasting before procedures, glucocorticoid therapy must be continued, by parenteral routes if necessary. A recent case report has highlighted the adverse consequences of omitting oral steroid therapy in a patient who was fasting before a surgical procedure. The patient developed hypotension and acute renal failure.
The patient described in the case report2 was admitted with septic arthritis. His usual cortisone dose of 12.5 mg had been omitted that evening, and his morning dose of 25 mg was not given the next day until after he had returned from the operating theatre. Over the next 3 days, he became overtly septic, and returned to theatre for another knee washout. Cortisone was not given during this time. When he developed acute renal failure on Day 5, dehydration and gentamicin toxicity were listed as possible causes.
The article by Jung and Inder does not make it clear that the case report contains nothing of relevance to the management of patients with adrenal insufficiency who are fasting for routine surgical procedures, as this man’s hypotension and acute renal failure actually developed over 5 days in the context of sepsis, dehydration and possible gentamicin toxicity, in addition to prolonged withholding of cortisone and two operations.
References
- Jung C, Inder WJ. Management of adrenal insufficiency during the stress of medical illness and surgery. Med J Aust 2008; 188: 409-413.
- Poulson LK. Acute adrenal insufficiency — withhold-ing of medicines in the peri-operative period. J Pharm Pract Res 2005; 35: 311-312. 0_pgfId-1816419