Management of Adrenal insufficiency in Critical care scenario by Dr. Om J Lakhani

00:00 🚂 Insights into the complexity and importance of understanding adrenal insufficiency in critically ill settings; it can often be a matter of life and death.
02:05 💉 Explanation of treatment plan for patients with pre-existing adrenal insufficiency that become critically ill.
04:37 📊 Discussion of the complications in assessing cortisol levels in ICU patients due to reduced cortisol binding globulin and albumin.
08:39 ⚕️ Explanation of primary, secondary, and tertiary adrenal insufficiency.
12:19 🧪 Description of an adrenal cortisol stimulation test, used to determine adrenal insufficiency.
14:09 🏥 Presentation of a case of "empty sella syndrome" caught via DHES assessment.
16:14 🔄 Mentioning the utility of DHEAS in patients already on hydrocortisone treatment.
17:35 🧠 Explanation of differentiating between primary, secondary and tertiary adrenal insufficiency using the ACTH level.
19:55 🦠 Discussion on the use of glucocorticoid in refractory septic shock and the controversial nature of its efficacy.
22:32 ⚖️ Noting the inconclusive nature of studies and meta-analysis involving the use of steroids in refractory septic shock.
26:09 🏥 Introduction of CIRCI (critical illness-related corticosteroid insufficiency) and its impact on long-term critically ill patients.
27:18 💊 Explanation on iatrogenic adrenal insufficiency and the possible drug causes.
30:06 🎯 Presentation of current guidelines on diagnosing CIRCI, including specific cut-offs for cortisol levels.
31:42 💡 Recommendation of lower steroid dose in treating CIRCI to avoid excess suppression of the endogenous HP Axis.
33:04 📌 Mention of the addition of fludrocortisone in patients with hyperkalemia suspected of primary adrenal insufficiency.
34:11 💊 Introduction of a cost-effective ACTH stimulation test using a drug called Acton Prolongatum, primarily used in India.
34:39 💉 Introduction of a cost-effective ACTH stimulation test in India using an intramuscular drug called Acton Prolongatum, which has been found to be as effective as the standard test.
35:06 🚀 Overview of how Sun Pharma in India brought in the standard ACTH stimulation test drug, Synacthen, to India around 2017-2018, but also noted the current global shortage of the drug.
36:57 📚 Emphasizing the importance of assessing adrenal insufficiency and how a missed diagnosis can be fatal.
37:40 📝 Summary of the steps in diagnosing adrenal insufficiency including a baseline cortisol, DHEA-S, and an ACTH stimulation test.
37:54 💭 Encouragement to consider the three different situations that might arise in a patient - undiagnosed adrenal insufficiency, refractory septic shock, or CIRCI.
38:22 🛑 Warning of the potential for iatrogenic adrenal insufficiency in critically ill patients due to drugs like etomidate, azoles, and glucocorticoids.

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