A 45-year-old woman is brought to the emergency department due to left groin and abdominal pain accompanied by nausea and vomiting. The patient has a history of systemic lupus erythematosus, hypertension, and glucocorticoid-induced hyperglycemia. Abdominal examination shows central obesity; skin striae; and a nonreducible, tender mass in the left groin. CT scan of the abdomen reveals a left femoral hernia containing a bowel segment and dilated small bowel loops. The patient undergoes urgent exploratory laparotomy for resection of the obstructed bowel loop and repair of the hernia. There are no intraoperative complications, but she abruptly develops hypotension in the postoperative recovery unit. Blood pressure remains

Question

A 45-year-old woman is brought to the emergency department due to left groin and abdominal pain accompanied by nausea and vomiting.  The patient has a history of systemic lupus erythematosus, hypertension, and glucocorticoid-induced hyperglycemia.  Abdominal examination shows central obesity; skin striae; and a nonreducible, tender mass in the left groin.  CT scan of the abdomen reveals a left femoral hernia containing a bowel segment and dilated small bowel loops.  The patient undergoes urgent exploratory laparotomy for resection of the obstructed bowel loop and repair of the hernia.  There are no intraoperative complications, but she abruptly develops hypotension in the postoperative recovery unit.  Blood pressure remains <90/60 mm Hg despite intravenous fluid boluses.  Which of the following is the best immediate step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8c9_2394_bc81_292e7fae6bc9_MD0003_00 Several aspects of this patient's presentation suggest that her refractory, acute-onset hypotension following surgery is due to adrenal crisis. Adrenal crisis can develop in the setting of an acute stressor (eg, illness, surgery) in patients with adrenal insufficiency (AI) (eg, chronic primary AI, secondary AI). This patient's history of systemic lupus erythematous (which often requires prednisone therapy for flares) and evidence of hypercortisolism (eg, central obesity, purple striae, glucocorticoid-induced hyperglycemia) suggest chronic glucocorticoid therapy. Patients on chronic glucocorticoid therapy can develop hypothalamic-pituitary-adrenal axis suppression and secondary AI. Because their pituitary gland is unable to increase ACTH secretion when needed (eg, acute stressor), these patients are at high risk of acute AI (adrenal crisis). Adrenal crisis primarily presents with hypotension and shock; hypoglycemia is also usually present. Adrenal crisis due to secondary AI may present less dramatically than that due to primary AI because only cortisol is deficient and angiotensin II-mediated aldosterone production remains intact (primary AI involves loss of both cortisol and aldosterone). However, cortisol does play an important role in maintaining vascular tone, and isolated cortisol deficiency can lead to hemodynamic collapse. aldosterone production The hypotension in adrenal crisis is often refractory to initial volume resuscitation, and treatment requires intravenous hydrocortisone or dexamethasone in addition to aggressive volume repletion. (Choices A, B, and C) CT scan of the abdomen can help diagnose postoperative intraabdominal hemorrhage leading to hemorrhagic shock, dobutamine infusion can be used to treat cardiogenic shock, and intramuscular epinephrine is used to treat anaphylactic shock. However, this patient's history of chronic glucocorticoid use and evidence of iatrogenic hypercortisolism make adrenal crisis due to secondary AI more likely. (Choice D) Intravenous colloid solutions (eg, albumin) are used in the treatment of hepatorenal syndrome and spontaneous bacterial peritonitis; however, crystalloid solutions (eg, normal saline, Ringer lactate) are preferred for volume resuscitation. Educational objective: Patients on chronic glucocorticoid therapy often have secondary adrenal insufficiency and can develop adrenal crisis when exposed to an acute stressor (eg, surgery, illness, trauma). Adrenal crisis primarily presents with hypotension and shock that is refractory to initial volume resuscitation. Treatment requires intravenous hydrocortisone or dexamethasone in addition to aggressive volume repletion. References: Adrenal crisis: still a deadly event in the 21st century. (http://www.ncbi.nlm.nih.gov/pubmed/26363354)

A 45-Year-Old Woman Is Brought to the Emergency Department Due