Background
Adrenal crises (AC) are episodes of severe adrenal insufficiency (AI) with hypotension. Cardiovascular compromise may not be detected in some patients leading to delays in emergency treatment.
Design
A retrospective study of paired systolic blood pressure (sBP) measurements in hospitalised patients with primary AI (PAI).
Patients
Patients with PAI and an acute medical illness admitted for urgent treatment between 2000 and 2017.
Measurements
A comparison between sBP on arrival at hospital and on discharge. Hypotension was classified as either absolute hypotension (sBP 100mg or lower) or relative hypotension (sBP over 100mg but at least 20mmHg lower than discharge sBP).
Results
There were 152 admissions with paired blood pressure measurements. Of these, 46 (30.3%) included a record of a medically diagnosed AC. Absolute hypotension was found in 38 (25.0%) records and a further 21 (13.8%) patients were classified as having relative hypotension. Patients aged 65 years and older had the lowest (14.8%, n=8) proportion with absolute hypotension but the highest (27.8%, n=15) with relative hypotension. Use of absolute and relative hypotension as the criterion for AC diagnosis increased the proportion of patients with an AC by 28.3% and the proportion of patients with an AC in the oldest age group by 130%.
Conclusions
Failure to detect cardiovascular compromise is common in older AI patients, underestimates the true rate of ACs in this group, and may result in delays in essential treatment. Relative hypotension should be assessed in all ill patients with AI.