Background: Adrenal crisis is a life threatening emergency with an incidence of 510 adrenal crises/100 patient-years with mortality around 0.5/100 patient-years.
Objective: Audit of inpatient adrenal crisis management was undertaken in line with Society for Endocrinology (SFE) guidance 2016 (Trust audit No:9763).
Methods: Retrospective evaluation of electronic and paper case records of 2 years (January 2017December 2018).
Results: Over 2-year period, 34 adrenal crises episodes in 25 patients (n=25; 13 M: 14 F) were identified. Mean age=50 years; mean length of stay=7 days. Hyponatraemia noted in 13/25 (52%); hyperkalaemia in 11/25 (44%). 19/25 (72%) received intravenous hydrocortisone; 25/25 (100%) steroid doses doubled. 24/25 (96%) were under Endocrine outpatient care; 12/25 (48%) received endocrine inpatient input. 2/25 (8%) died of malignancy; none from adrenal crisis (Table 1).
Discussion: Although compliant in majority of measures, suboptimal management was noted in providing inpatient endocrine input, patient information dissemination, medic alert advice etc. Following interventions were undertaken:
|IV Hydrocortisone||18/25 (72%)|
|IV fluids||23/25 (92%)|
|Endocrine input||12/25 (48%)|
|Tapering steroid dose instruction||23/25 (92%)|
|Endocrinology outpatient follow-up||25/25 (100%)|
|Emergency hydrocortisone kit||21/25 (84%)|
|Medic-alert device advice||5/25 (20%)|
|Steroid Emergency Card||21/25 (84%)|
|Patient education leaflets, website etc||0% recorded in notes|
|Doubling of steroids||25/25 (100%)|
1. Adrenal crisis Trust guideline in accordance with SFE was introduced (1).
2. Electronic prescribing alert of intravenous hydrocortisone and doubling of steroids was inserted to remind clinicians, similar to Newcastle upon Tyne model (2).
3. Electronic alert of steroid-dependent patients upon admission is currently underway.
Learning point: We feel that clinician awareness is vital for optimal management of adrenal crisis. Electronic prescription alert of emergency steroid management as well as electronic steroid dependent patient alert at the point of admission will aid reduce morbidity and potentially mortality.