On 2nd December 2017, Aster Hospital’s Critical Care Department encountered a 30 year old male patient who experienced vomiting multiple times, had profuse sweating and general uneasiness with myalgia. The patient was brought to the ER, and was found to have tachycardia and hypotension. He was diagnosed with;
- Adrenal insufficiency (shock)/Septic shock
- Acute kidney injury – Ischemic Acute Tubular Necrosis.
- Acromegaly with panhypopituitarism on replacement therapy
He was then shifted to the ICU in view of refractory hypotension and was aggressively resuscitated with IV fluid boluses and Vasopressors and IV Hydrocortisone 100mg thrice a day with Empirical Antibiotics. The patient was put on NRBM 12 liters/min oxygen as room air saturation was 90%, then Tab. Thyronorm 75 mcg was added. The patient continued to remain drowsy, diaphoretic and hypotensive in spite of all resuscitative efforts. Repeated capillary blood glucose was done to maintain Euglycemia with [email protected] IV infusion. Standby plan for intubation was made in view of worsening GCS and Hemodynamic instability. After 12 hours, since admission to ICU, the patient showed significant improvement in Hemodynamics, improved sensorium, coherent, taking fluid diets orally. By now around 10 liters of IV fluid, 200mg IV Hydrocortisone, Vasopressors ([email protected] mcg/kg/min- being tapered) were going.
In view of worsening renal functions, high creatinine and BUN with metabolic acidemia, Fluid resuscitation was continued. Dyselectrolytemia like Hyperphosphatemia was corrected with Inj. Frusemide 40mg 1-1-0 and Tab. Sevelamer 800 mg thrice a day. Tab. Sodium bicarbonate 650 mg (half), later full doses thrice a day was given. Renal replacement therapy was planned in case of metabolic acidosis worsening along with dyselectrolytemia. The patient improved slowly but steadily. Targeting positive fluid balance, daily monitoring of the renal parameters was done. BUN and S.Creatinine showed significant improvement over the next few days. The patient was discharged by the 10th day. He followed up in Nephrology and Endocrine clinics, as advised.
The idea of presenting this case is to identify Adrenal Crisis/Shock and keep an open mind as shock may have mixed etiology and need not necessarily be septic as most commonly encountered. Taking a proper history and data collation will help managing such patients.
Specialist Physician and H.O.D of Critical Care Medicine
Specialist in Internal Medicine
Aster Hospital, Mankhool