Questions of the Week for 3/19/2024
Author: Christian Gerhart
Q: A patient has hypopituitarism and is boarding in the ED after being admitted for sepsis. What home medications are these patients usually on that may need to be ordered while the patient is boarding in the ED?
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Hydrocortisone + fludrocortisone: Patients with hypopituitarism are generally on these medications since they do not make sufficient ACTH (made in the anterior pituitary) to stimulate the adrenal glands. Consider the addition of stress dosing in the setting of acute infection or stressed state. If patients go an extended period of time without their steroids this can lead to acute adrenal insufficiency.
Desmopressin: The posterior pituitary usually makes anti-diuretic hormone (ADH) and thus most patients will be on oral desmopressin as replacement. Missing doses can lead to sodium/free water dysregulation.
Levothyroxine: TSH is made in the anterior pituitary. Thyroid hormone replacement is usually required for these patients. This is usually not as time sensitive as the other medications.
Q: You have a patient admitted to the ICU with septic shock from pneumonia. They have received 3L of IV fluids and are started on norepinephrine for refractory hypotension. Their bedside echo does not show any abnormalities. They require escalating norepinephrine doses and vasopressin is added. What additional medication should be considered?
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Stress dose steroids (hydrocortisone +/- fludrocortisone) are probably indicated regardless of the underlying infectious source given the patient’s refractory instability. The dosing for stress dose steroids is variable but generally giving a 100 mg bolus of hydrocortisone followed by 50 mg q 6 hours should be sufficient. If fludrocortisone is added, this can be dosed at 50 ug. A recent systematic review in JAMA seems to support the practice of fludrocortisone administration in addition to hydrocortisone in septic shock. (3) Hydrocortisone does have some mineralocorticoid properties so some question the utility of fludrocortisone if using hydrocortisone. If you choose to use dexamethasone or methylprednisolone then it is generally suggested to add fludrocortisone as these lack sufficient mineralocorticoid activity. The society of Critical Care Medicine recommends steroids for severe community acquired pneumonia which would be an additional indication in this patient. (1)
Q: What electrolyte abnormalities can be seen in adrenal insufficiency?
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In primary adrenal insufficiency (Addison's disease), which is a problem with the adrenal gland itself, hyperkalemia and hyponatremia are commonly seen electrolyte abnormalities. Hyponatremia is caused by ADH dysregulation and renal dosium loss, whereas hyperkalemia is caused by low aldosterone. In secondary adrenal insufficiency (problem with pituitary gland), hyponatremia can be seen but hyperkalemia is less commonly seen.
Q: The following intubation video is from EMCrit. What errors can you identify from this clip?
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Insertion off midline
Overly deep insertion leading to esophageal visualization
Failure to engage midline of vallecula
Inadequate lifting force
Mac used as a Miller (debatable whether this represents an error)
Initially the blade was inserted to the right of the midline. It was then advanced too deep, which resulted in visualization of the esophagus. Once the blade was retracted, it was slightly off midline though with additional lifting force it may have been possible to obtain an adequate view of the glottis. When an adequate view was unable to be obtained, the operator used the Mac blade as a Miller and directly lifted the epiglottis which allowed them to pass a bougie.
Q: You obtain the view seen in this video (https://www.youtube.com/watch?v=L8rWOJ1ykT4&t=10s) when performing video laryngoscopy. What is this called and what complication can this lead to?
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This exposure of the anterior cricoid ring is called the “Kovacs sign”, named after airway guru George Kovacs (video from his website, https://aimeairway.ca/). This is representative of an overly deep laryngoscope insertion and is associated with challenging tube delivery. This is particularly common with hyperangulated video laryngoscopy. It is generally recommended that the operator attempt to have a percent of glottic opening (POGO) of approximately 50% with hyperangulated video laryngoscopy which allows for easier tube delivery.
More here: https://www.acepnow.com/article/tips-for-using-a-hyperangulated-video-laryngoscope/?singlepage=1
Q: Where should the gallbladder wall be measured on a RUQ ultrasound?
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The wall should be measured on the anterior surface of the gallbladder wall next to the hepatic parenchyma. Measuring on the posterior surface may lead to an inaccurately high measurement due to posterior acoustic enhancement.
References:
1) Pastores SM, Annane D, Rochwerg B; Corticosteroid Guideline Task Force of SCCM and ESICM. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med. 2018;44(4):474-477. doi:10.1007/s00134-017-4951-5
2) Alexandraki KI, Grossman A. Management of Hypopituitarism. J Clin Med. 2019;8(12):2153. Published 2019 Dec 5. doi:10.3390/jcm8122153
3) Bosch NA, Teja B, Law AC, Pang B, Jafarzadeh SR, Walkey AJ. Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock. JAMA Intern Med. 2023;183(5):451–459. doi:10.1001/jamainternmed.2023.0258
4) Abdalla M, Dave JA, Ross IL. Addison's disease associated with hypokalemia: a case report. J Med Case Rep. 2021;15(1):131. Published 2021 Mar 25. doi:10.1186/s13256-021-02724-6