Prehospital Management of Acute Addison Disease: Audit of Patients Attending a Referral Hospital in a Regional Area

Abstract

Context Adrenal crisis (AC) causes morbidity and mortality in patients with Addison disease [primary adrenal insufficiency (PAI)]. Patient-initiated stress dosing (oral or parenteral hydrocortisone) is recommended to avert ACs. Although these should be effective, the continued incidence of ACs remains largely unexplained. Methods Audit of all attendances between 2000 and 2017 of adult patients with treated PAI to one large regional referral center in New South Wales, Australia. Measurements were those taken on arrival at hospital. Results There were 252 attendances by 56 patients with treated PAI during the study period. Women comprised 60.7% (n = 34) of the patients. The mean age of attendees was 53.7 (19.6) years. Nearly half (45.2%, n = 114) of the patients had an infection. There were 61 (24.2%) ACs diagnosed by the treating clinician. Only 17.9% (n = 45) of the hospital presentations followed any form of stress dosing. IM hydrocortisone was used prior to presentation 7 (2.8%) attendances only. Among patients with a clinician-diagnosed AC, only 32.8% (n = 20) had used stress dosing before presentation. Vomiting was reported by 47.6% (n = 120) of the patients but only 33 (27.5%) of these attempted stress dosing and 5 patients with vomiting used IM hydrocortisone. The number of prior presentations was an independent predictor of use of stress doses [1.05 (1.01, 1.09)]. Conclusion Dose-escalation strategies are not used universally or correctly by unwell patients with PAI; many patients do not use IM or subcutaneous hydrocortisone injections. Previous hospital treatment increases the likelihood of stress dosing, and hospital attendance offers the opportunity for reinforcement of prevention strategies.

Acute illness in children with secondary adrenal insufficiency

“…Unlike stress dose use in CAH patients drawn from the same general population, there was no relationship with patient age and use of dose escalation strategies 12 . Previous attendance for an acute illness was found to be positively associated with the use of dose escalation prior to hospital in these patients, which is consistent with the evidence from other studies and suggests that lived experience of an acute illness episode is an important element in the development of competency in self‐management in AI patients 12,25,26 …”

“…12 Previous attendance for an acute illness was found to be positively associated with the use of dose escalation prior to hospital in these patients, which is consistent with the evidence from other studies and suggests that lived experience of an acute illness episode is an important element in the development of competency in self-management in AI patients. 12,25,26 Children with comorbid DI were found to have more attendances with electrolyte derangements including hypernatremia and hyponatraemia. They also were found to have a higher number of episodes with blood glucose levels lower than 3.5 mmol/L, a phenomenon that may be related to lower levels of circulating cortisol in the context of a lower frequency of stress dose use in this group.…”

Interaction between hypotension and age on adrenal crisis diagnosis

“…Hyponatraemia (serum sodium less than 135 mmol/L) was found in 48.7% (n = 74) and hyperkalaemia (serum potassium greater than 5.0 mmol/L) in 21.1% (n = 32). The distribution of other relevant clinical details for these patients was reported previously 10 …”

“…The design of the study and the description of the PAI patient population have been reported previously 10 . Briefly, the study comprised a retrospective audit of the medical records of patients with at least one admission to a large regional hospital in which there was a principal or comorbid diagnosis of PAI 10 .…”

“…The design of the study and the description of the PAI patient population have been reported previously 10 . Briefly, the study comprised a retrospective audit of the medical records of patients with at least one admission to a large regional hospital in which there was a principal or comorbid diagnosis of PAI 10 . For the present analysis, all patients included in the sample had PAI, were on replacement therapy and had been admitted to hospital between 2000 and 2017 for the treatment of an acute medical illness.…”