Adrenal Atrophy and Irreversible Shock Associated With Cortisone Therapy

Abstract

Recent clinical observations and animal experiments 1 have shown that prolonged administration of cortisone produces adrenal atrophy. According to the adaptation syndrome of Selye,2 adrenal atrophy in turn may lessen the body's ability to withstand trauma and stress. One might suspect that patients receiving cortisone would not normally withstand major surgery; yet every day patients are successfully undergoing surgery while regularly taking cortisone in both the preoperative and postoperative periods.We wish to present the record of a patient who, while receiving a prolonged course of cortisone therapy, underwent a major operation, cup arthroplasty of the hip, and died of immediate postoperative shock, in spite of normally adequate, aggressive antishock therapy. Postmortem examination revealed marked bilateral adrenal atrophy and other conditions consistent with shock. REPORT OF A CASEA 34-year-old man had had rheumatoid arthritis for a period of seven years. Almost every joint of his body was involved, particularly the hips, where there was a marked flexion contracture. The patient had been receiving cortisone for eight months. He first received 1,200 mg. of cortisone over a period of 10 days and then 100 mg. three times weekly. For two months prior to the present examination the patient had been taking 25 mg. of cortisone twice a day. Because of the pain in the right hip and flexion deformity, a cup arthroplasty in the right hip was advised.Past History.-The patient had the usual childhood diseases, including smallpox, and had hay fever. Several episodes of mild skin petechiae were diagnosed as allergic purpura; the latest occurred after his use of cortisone. Bleeding, clotting, and prothrombin times were normal. The platelet count was normal.Physical Findings.-Physical examination revealed a chronically ill-appearing, deformed man of 34 years, who was able to walk about in a stooped position with the use of crutches. He did not appear to be in acute pain. There was pronounced evidence of generalized rheumatoid arthritis. The heart and lungs were normal. Laboratory Data.-X-ray studies revealed an essentially normal chest. The heart measured nearly 50% of the transverse diameter of the chest and was not enlarged in any one region. The red blood cell count was 4,220,000 and hemoglobin 13 gm. I per 100 cc. Urinalysis disclosed no abnormalities. Serologie studies revealed nothing essentially abnormal. The white cell count was 11,000, with 72% neutrophils, 19% lymphocytes, 8% monocytes, 1 basophil, and no eosinophils.Course in the Hospital.-The patient received cortisone up to the time of admission and two days later was taken to the operating room. Spinal anesthesia was employed, with tetracaine (pontocaine®) hydrochloride supplemented with thiopental sodium. The blood pressure at the beginning of the operation was 140/80 and the pulse rate 72. A routine cup arthroplasty of the right hip was performed. During the course of surgery the patient received one blood transfusion. His blood pressure did not fall below 11...

Corticosteroid Therapy in Severe Illness

“…When blood pressure during and after surgery is taken as Unexplained circulatory instability Discrepancy between the anticipated severity of the disease and the present state of the patient, including nausea, vomiting, orthostatic hypotension, dehydration, abdominal or flank pain (indicating acute adrenal hemorrhage), fatigue, and weight loss High fever without apparent cause (negative cultures), not responding to antibiotic therapy Unexplained mental changes: apathy or depression without a specific psychiatric disturbance Vitiligo, altered pigmentation, loss of axillary or pubic hair, hypothyroidism, hypogonadism Hypoglycemia, hyponatremia, hyperkalemia, neutropenia, eosinophilia the end point, neither basal nor corticotropin-stimulated serum cortisol concentrations predict changes in blood pressure in corticosteroid-treated patients undergoing surgical stress without corticosteroid supplementation. 40,73,79 A number of case histories and more extensive studies of corticosteroid-treated patients 5,[9][10][11]25,40,[81][82][83] describe the catastrophic effects of hypocortisolism during surgery and the dramatic beneficial effects of corticosteroid therapy. In retrospect, however, many confounding factors were present that make the interpretation of these reports difficult.…”

Preoperative evaluation of adult patients before elective, noncardiothoracic surgery

“…Case studies indicate a correlation between cortisol deficiency and intraoperative hypotension or shock, although this has not yet been unequivocally proven [49,50]. Therefore, in general, patients should not interrupt their long-term steroid medication in the perioperative phase and take this as normal on the morning of surgery.…”

Präoperative Evaluation erwachsener Patienten vor elektiven, nicht Herz-Thorax-chirurgischen Eingriffen

“…Kasuistische Berichte postulieren einen -letztlich nicht sicher belegten -Zusammenhang zwischen einem Cortisolmangel und einer intraoperativen Hypotension bzw. einem Schockgeschehen [49,50] …”