CARE OF THE CRITICALLY ILL CHILD: ACUTE ADRENAL INSUFFICIENCY

Abstract

Although critical illness may occur in the course of chronic adrenal insufficiency (Addison's disease ), the causes of acute adrenal insufficiency in childhood are generally different. These include aplasia or hypoplasia of the adrenal gland in infancy, adrenal hemorrhage (usually in the newborn ), fulminating infections (rarely ), discontinuation of steroid therapy, and unilateral adrenalectorny for a tumor causing Gushing's syndrome. In addition, there are certain salt-losing syndromes associated with a relatively low aldosterone secretion, occurring either as primary diseases or in conjunction with classical, congenital, virilizing adrenocortical hyperplasia. There is actually little proof that fulminating infections, per se, cause acute adrenal insufficiency, whereas a body of evidence suggests ample adrenocortical response most of the time. This applies to the secretion of the corticoids as well as aldosterone. Thus, empirical use of steroids to treat serious infection is not sanctioned here.

The keys to therapy of adrenocortical failure include fluid and electrolyte replacement as well as appropriate steroid hormone replacement. Approxim ately 100 to 120 ml of isotonic saline solution per kilogram of body weight should be administered intravenously to children weighing up to 20 kg within the first 24 hours, and 75 ml per kilogram should be administered when the weight is above 20 kg. These recommendations are based on the special situation applicable to the dehydration of adrenal failure where extracellular fluid loss pnedominates. When shock is especially severe, 5 ml of plasma per kilogram may be substituted volume for volume as part of the mitial replacement fluid.