Diabetic ketoacidosisIt is an acute metabolic complication of insulin dependent (type 1) diabetes and occasionally of non insulin dependent (type 2) diabetes mellitus encountered during infection, trauma, cardiovascular injuries or other acute emergencies. Hyperglycaemic hyperosmolar coma (nonketotic hyperosmolar coma)Clinical presentation and pathogenesis of nonketotic coma are similar to DKA. Addisonian crisis: Acute adrenal insufficiencyThe common causes of acute adrenal insufficiency include autoimmune disorders, infection, sudden withdrawal of adrenal replacement therapy, haemorrhage into adrenal glands, purpura fulminans or sudden failure of adrenal or pituitary functioning due to infection or trauma. The most common acute complication observed with pituitary disorder, whether operated or non-operated, is the severe diabetes insipidus (DI). Red hot chili peppers bassist flea threatens crotch-slip during 2014 super bowl xlviii halftime show performance via twitter, Super bowl weekend is upon us and the celebrities have already started to flood new york city. Foo fighters, red hot chili peppers, the roots to play super bowl concerts - The musical festivities at this year’s super bowl won’t be limited to bruno mars’ halftime performance. Red hot chili peppers bassist flea threatens crotch-slip during 2014 super bowl xlviii halftime show performance via twitter - Super bowl weekend is upon us and the celebrities have already started to flood new york city. Foo fighters, red hot chili peppers rock nyc saturday super bowl concerts - Meanwhile, the red hot chili peppers took the barclays obliquely referenced rhcp's coming super bowl performance and gave a nod to the band's 2014 plans. How vips are partying this super bowl weekend - If you want to be an mvp this weekend, you’d better be a vip. Students from three Parisian high schools were put away Monday morning, following threats for the third time in a week in establishments of the capital, the rector of Paris said.It is this time of Condorcet institutions, Henry IV and Louis-le-Grand, said the Rector on his official Twitter account, information from police sources confirmed. SubscribeEnter your email address below to receive updates each time we publish new content.
The foundations of the alliance of Western states against the fighters of the Islamic state were asked at the Paris conference on Monday. However, the patients are usually elderly who present with diabetes for the first time and are severely dehydrated, hyperglycaemic and often in coma. This is commonly observed in patients undergoing intracranial surgery for removal of pituitary tumour or severe head injury with bleed into the pituitary.
Role of the hypothalamic-pituitary-adrenal axis, glucocorticoids and glucocorticoid receptors in toxic sequelae of exposure to bacterial and viral products.
Science review: Mechanisms of impaired adrenal function in sepsis and molecular actions of glucocorticoids. Hyperglycemic crises in diabetes mellitus: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Proinflammatory cytokines, markers of cardiovascular risks, oxidative stress, and lipid peroxidation in patients with hyperglycemic crises. Regulation of steroidogenesis and the steroidogenic acute regulatory protein by a member of the cAMP response-element binding protein family. Total long-term within-laboratory precision of cortisol, ferritin, thyroxine, free thyroxine, and thyroid-stimulating hormone assays based on a College of American Pathologists fresh frozen serum study: Do available methods meet medical needs for precision?
Measurement of serum free cortisol shows discordant responsivity to stress and dynamic evaluation.
A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. Anesthesia and Intensive care implications for pituitary surgery: Recent trends and advancements.

On the term "relative adrenal insufficiency"-or what do we really measure with adrenal stimulation tests? Implications and considerations during pheochromocytoma resection: A challenge to the anesthesiologist.
Renal endocrine manifestations during polytrauma: A cause of concern for the anesthesiologist. The anesthetic, critical care and surgical challenges in the management of craniopharyngioma. Severe deficiency of insulin leads to reduction of glucose uptake and its utilisation by muscle, fat and liver while glycogenolysis and gluconeogenesis is enhanced.
The presentation is delayed due to absence of ketosis but the management strategies are similar to that of DKA. Nonspecific symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever and confusion may be present in critically ill patients which can progress to coma. There is increased lipolysis, leading to formation of ketone bodies (acetone, beta-hydroxybutyric acid, and acetoacetic acid) and results in development of anion gap metabolic acidosis.
The lab findings support the clinical picture and demonstrate lack of urine concentrating ability.ManagementDesmopressin (DDAVP) is the cornerstone of this clinical entity and is administered by careful titration of urine output, electrolytes and serum osmolarity. Mortality is high because of associated concurrent illness, thrombotic events or infections.
Though various routes such as intravenous, subcutaneous, intranasal and oral can be used for DDAVP administration, however intranasal which avoid the first pass metabolism in hepatic tissue and intravenous are the best. The technical limitations of ICU discourage the performance of tests which suppresses the adrenal functions such as insulin response test and metyrapone inhibition. Intravascular volume depletion due to osmotic effects leads to dry mucous membranes, sunken eyeballs, tachycardia, orthostatic hypotension, and even supine hypotension.
During the postoperative course these patients are highly susceptible to development of hypertension, hypotension and hypoglycaemia. It is one of the most dreaded complications of thyroid gland occurring in less than 10% of patients hospitalized for thyrotoxicosis and is nine to ten times more common in women than in men. For ACTH stimulation test 250 μg cosyntropin is given intravenously and serum cortisol levels measured at 0, 30, and 60 minutes. Thyroid storm can be precipitated by a number of factors such as severe infections, diabetic ketoacidosis, surgery, trauma, pulmonary thrombo-embolism, direct trauma or surgical manipulation of the thyroid gland, iodine administration or following discontinuation of anti-thyroid medications. High anion gap metabolic acidosis is invariably present; however, if frequent vomiting occurs, mixed metabolic acidosis and alkalosis picture may supervene. The clinical profile may also exhibit hyperosmolarity, increased serum and urinary ketone levels, mild hyponatremia, and hypocalcemia. Gastrointestinal involvement is manifested as nausea, vomiting, diarrhoea and abdominal pain. In case of hypotension ACTH stimulation test is delayed and dexamethasone is used 3-4 mg every 6-8 hours.
These can be primary manifestations, arising from trauma or can occur secondary to surgical procedures which may involve phaeochromocytoma, pituitary tumour and craniopharyngioma and so on. Serum potassium levels are usually normal at presentation due to extracellular shift of potassium but once the treatment is initiated, hypokalemia may become clinically manifest.

The dose of hydrocortisone is reduced to replacement level (10-20 mg morning and 5-10 mg evening) once the condition improves. Fluid and electrolyte replacement should be done at the earliest as timely aggressive management helps in elimination of vasopressor dependence, shortened ICU stay and better outcome.
Total and free thyroxine (T 4 ) and tri-iodothyronine (T 3 ) are increased while thyrotropin (TSH) levels are reduced. Careful evaluation of clinical history and a high degree of suspicion are the corner stone to diagnose such problems. Total body water deficit may be up to 10-12 L and replacement is usually started with 0.9% sodium chloride (NS). Aggressive management of the patient is equally important as the complications are devastating and can prove highly fatal.
Oxygen therapy, management of hypertension, fluid and electrolyte replacement, antipyretics, environmental cooling, management of cardiac arrhythmias and heart failure should be initiated at the earliest. When ketones levels disappear and the patient accepts oral intake, subcutaneous insulin therapy can be initiated with an overlap of about 30 minutes with insulin infusion.
Potassium deficit may persist after DKA is treated and hence, oral replacement should continue.
The common causes such as fever, infection, stress, pain and others should be managed in the swiftest of manner.
A further fall during treatment may lead to hypophosphatemia syndrome characterized by decreased myocardial contractility, respiratory muscle weakness and respiratory failure, hemolysis, and rhabdo-myolysis.
It usually develops in a previously hypothyroid patient developing severe intercurrent illness or in inadequately treated and undiagnosed case of hypothyroidism.
Haemodynamic and conduction disturbances may manifest in the form of bradycardia, prolonged QT interval, diminished cardiac output, pericardial effusion which may ultimately leads to cardio-vascular collapse. There may be visual disturbances, dizziness, confusion, headache, tingling, difficulty in speaking, and concentrating. Central nervous system may show altered responses to hypercarbia and hypoxia and the associated respiratory muscle weakness may lead to hypoventilation and respiratory failure. There may be generalized skin and soft tissue swelling, periorbital edema, ptosis, macroglossia, and the presence of cool, dry skin. The laboratory profile may reveal hyponatremia, hypoglycaemia, hypercapnia and respiratory acidosis. Intravenous tri-iodothyronine can be given as an initial bolus dose of 10-20 mcg, followed by 10 mcg every 4-24 hours, with taper to 10 mcg every 6 h.
Treatment of the precipitating causes.Supportive therapy includes oxygen therapy, non-invasive or invasive ventilation if required, passive warming, management of hypoglycaemia and hyponatremia and use of vasopressors to manage hypotension.

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