IV fluids Initial treatment with normal saline 10-20mL/kg depending on level of dehydration. The updated JRCALC 2017 Clinical Practice Guidelines incorporate new ambulance guidelines on adrenal crisis, following input from the ADSHG and The Pituitary Foundation, steered by the Chair of the ADSHG’s clinical advisory panel, Prof John Wass. administration of 0.9% saline solution (or equivalent). Follow-up of patients not undergoing adrenal (For diagnostic workup, see, 3.1 We recommend glucocorticoid therapy in all patients with confirmed PAI. or i.m. (Ungraded best practice statement), 5.3 We suggest periodic screening for autoimmune diseases known to be more prevalent in PAI patients in whom autoimmune origin of PAI has not been excluded. (1|⊕⊕⚪⚪), 4.1 We recommend that patients with suspected adrenal crisis should be treated with an immediate parenteral injection of 100 mg (50 mg/m2 for children) hydrocortisone, followed by appropriate fluid resuscitation and 200 mg (50–100 mg/m2 for children) of hydrocortisone/24 hours (via continuous iv therapy or 6 hourly injection); age- and body surface-appropriate dosing is required in children (see, 4.2 If hydrocortisone is unavailable, we suggest prednisolone as an alternative. This card and its associated guidance is intended for use by adults (16+), The BSPED Paediatric Steroid Treatment Card provides a succinct steroid management plan for illnesses, emergency injections and blood sugar & electrolyte correction. Adrenal crisis usually presents between the first and fourth week of life. (Ungraded best practice statement), 5.1 We suggest that adults and children with PAI be seen by an endocrinologist or a healthcare provider with endocrine expertise at least annually. due to illness with fever, persistent vomiting or diarrhoea, trauma or childbirth. prevention and emergency management of adult patients with adrenal insufficiency, Steroid card bulletin and implementation flowchart, COVID-19 resources for managing endocrine conditions. Introduction. The Society for Endocrinology Steroid Emergency Card working group has suggested these sick day rules in line with most recent evidence of cortisol response to illness, and guidance for management of AI for patients with COVID-19 (Prete JCEM 2020, Arlt EJE 2020). Hydrocortisone intramuscularly or intravenously should be administered before transfer to hospital. The syndrome of adrenal crisis (acute adrenal insufficiency) in adults may occur …. Guidelines Summary. (2|⊕⊕⊕⚪), 3.6 We suggest against hormonal monitoring of glucocorticoid replacement and to adjust treatment only based on clinical response. Diagnosis. Treatment requires the replacement or substitution of the hormones that the adrenal glands ceased to produce and should begin as soon as the diagnosis is confirmed. Diagnosis and Treatment of Primary Adrenal Insufficiency, Primary Adrenal Insufficiency Guideline Resources, Accelerating Breakthroughs & Improving Care, Treating and diagnosing patients during and after an adrenal crisis, Testing and diagnosing in optimal circumstances, Setting a regimen for glucocorticoid and mineralocorticoid replacement, Treatment and monitoring in pregnancy and childhood, Managing adrenal crisis in diagnosed individuals. Guidance during the initial phase of assessment and management of acute adrenal insufficiency (adrenal crisis) in adult patients. If patient has suspected acute adrenal insufficiency: Diagnostic measures should never postpone treatment and if adrenal crisis is suspected, treatment should be initiated without delay. A recent review paper on the management of adrenal insufficiency made recommendations for the prevention and treatment of adrenal crisis, but with little detail applicable to the peri‐operative setting 4. (1|⊕⊕⊕⚪), 2.6 We suggest that the etiology of PAI should be determined in all patients with confirmed disease. Adrenal crisis can be a manifestation of previously undiagnosed adrenal failure. If adrenal crisis is suspected, the person is acutely unwell or hypotensive, emergency admission should be arranged — untreated adrenal crisis can be rapidly fatal. or i.m. (2|⊕⊕⚪⚪), 4.3 For the prevention of adrenal crisis, we suggest adjusting glucocorticoid dose according to severity of illness or magnitude of the stressor. Then take the next step: Set up your free website account and get exclusive access to even more great tools & content! followed by rapid rehydration with i.v. Find out more by reading the recommendations and related resources from our clinical practice guideline, Diagnosis and Treatment of Primary Adrenal Insufficiency. View in Chinese. Clinical studies, case reports and current guidelines / treatment protocols. The Society for Endocrinology has endorsed a joint guidance document written together with Specialist Pharmacy Services. An adrenal crisis may be the first presentation of who do not suppress to <50 nmol/L after 1 mg dexamethasone overnight. Please immediately inject 100mg hydrocortisone i.v. or i.m. In this article, we will discuss the Treatment of Acute Adrenal Crisis/Insufficiency.So, let’s get started. injection of 50mg hydrocortisone every 6 hours) until clinical recovery and further guidance by an endocrinologist. A growing number of AI cases are due to side effects of GC treatment used in different treatment … (1|⊕⊕⊕⊕), 1.3 In patients with severe adrenal insufficiency symptoms or adrenal crisis, we recommend immediate therapy with iv hydrocortisone at an appropriate stress dose prior to the availability of the results of diagnostic tests. (1|⊕⊕⚪⚪), 3.17 We recommend hydrocortisone stress dosing during the active phase of labor, similar to that used in major surgical stress. The card clearly outlines first management steps in an emergency. (1|⊕⊕⊕⚪), 2.1 We suggest the standard dose (250 μg for adults and children ≥2 y of age, 15 μg/kg for infants, and 125 μg for children <2 y of age) iv corticotropin stimulation (30 or 60 min) test over other existing diagnostics tests to establish the diagnosis of adrenal insufficiency. A gr … infusion, alternatively by i.v. 1.1 We recommend diagnostic testing to exclude primary adrenal insufficiency (PAI) in acutely ill patients with otherwise unexplained symptoms or signs suggestive of PAI (volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain, hyperpigmentation or, especially in children, hypoglycemia). (Ungraded best practice statement), 4.6 We recommend that every patient should be equipped with a glucocorticoid injection kit for emergency use and be educated on how to use it. This evidence-based guideline was developed by a committee including all authors, and was reviewed by a subcommittee of the Japan Endocrine Society. Adherence to the guidelines in patients with adrenal crisis should ideally be monitored every 18 months by an audit, with input from endocrinology and chemical pathology. The preferred treatment of adrenal insufficiency is oral hydrocortisone which is the most physiological option for cortisol replacement available today. Approach to the infant or child with nausea and vomiting. The National Reporting and Learning System (NRLS) identified 78 incidents … Emergency management of an Addisonian Crisis (acute adrenal insufficiency) Immediate management: 1. (1|⊕⊕⊕⚪), 2.5 We recommend the simultaneous measurement of plasma renin and aldosterone in PAI to determine the presence of mineralocorticoid deficiency. Adrenal crisis can also occur in patients with known adrenal insufficiency if existing cortisol replacement does not meet the increased need for cortisol, e.g. Primary adrenal insufficiency is associated with both cortisol and mineralocorticoid deficiency. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency (Clinical Medicine, July 2020), The Society for Endocrinology, the Association of Anaesthetists and the Royal College of Physicians have published new Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms often leading to misdiagnosis and delayed treatment. We suggest measuring serum cortisol levels at 8–9 am as the first-line test for diagnosing central adrenal insufficiency.. We recommend against using a random cortisol level to diagnose AI.. We suggest that a cortisol level <3 μg/dL is indicative of adrenal insufficiency and … Establish venous access and draw blood for U&Es, glucose, cortisol and … Guidelines from Britain’s Society for Endocrinology on the emergency management of adrenal crisis, published in 2016, include the following diagnostic recommendations [ 16] : Adrenal insufficiency should be ruled out in any acutely ill patient with signs or symptoms potentially suggestive of acute adrenal insufficiency. It is considered one of the endocrine emergency precipitated by an internal or external process in the setting of known or unknown lack of production of the adrenal hormone cortisol, the major glucocorticoid. (2|⊕⊕⚪⚪), 3.5 We suggest monitoring glucocorticoid replacement using clinical assessment including body weight, postural blood pressure, energy levels, signs of frank glucocorticoid excess. Endocrine Society is a global community of physicians and scientists dedicated to accelerating scientific breakthroughs and improving patient health and well being. Dexamethasone is the least-preferred alternative and should only be given if no other glucocorticoid is available. (2|⊕⚪⚪⚪), 3.11 We suggest a trial of dehydroepiandrosterone (DHEA) replacement in women with PAI and low libido, depressive symptoms, and/or low energy levels despite otherwise optimized glucocorticoid and mineralocorticoid replacement. Arlt W, Society for Endocrinology Clinical Committee. Monitor EKG for signs of hyperkalemia which can be present in patients with adrenal crisis. Emergency treatment should never be delayed to carry out investigations. Patients taking exogenous glucocorticoids across any route (oral, intra-articular, intra-muscular, inhaled, nasal and topical preparations) being used to treat a variety of medical conditions, can cause adrenal insufficiency by suppressing the hypothalamo-pituitary-adrenal axis. Adrenal insufficiency (AI) is a life-threatening condition requiring life-long glucocorticoid (GC) substitution therapy, as well as stress adaptation to prevent adrenal crises. 100 mg hydrocortisone IV or IM stat o Then 50 mg hydrocortisone IV QDS or 200 mg/24 hours IVI 2. Steroid replacement therapy Information for patients (University of Leeds), Hydrocortisone Sick Day Rules - The Pituitary Foundation, Keeping safe with adrenal insufficiency - The Pituitary Foundation, Newly Diagnosed - Sick Day Rules - Addison's Disease Self-Help Group, Dr Helen L Simpson, FRCP, PhD (Chair)Consultant EndocrinologistRCP Patient Safety CommitteeDepartment of Diabetes and Endocrinology, UCLH NHS Foundation Trust, Dr Yasir ElhassanConsultant EndocrinologistQueen Elizabeth Hospital Birmingham and University of Birmingham, Dr Anna L MitchellConsultant endocrinologistNewcastle upon Tyne Hospitals NHS Foundation Trust, Dr Michael O’ReillyConsultant Endocrinologist Beaumont Hospital DublinClinical Associate Professor Royal College of Surgeons in Ireland (RCSI), Dr Robert D MurrayConsultant Endocrinologist & Honorary Associate ProfessorLeeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Professor Jeremy TomlinsonNIHR Oxford Biomedical Research Centre and University of Oxford, Professor John WassProfessor of Endocrinology, Oxford University.GIRFT lead for Endocrinology, NHS England, Dr Antonia Brooke FRCP, MD, MAMacLeod Diabetes and Endocrine CentreRoyal Devon and Exeter Foundation Trust, Alessandro Prete, MDClinical Research Fellow in Endocrinology and DiabetesInstitute of Metabolism and Systems Research, University of Birmingham, Professor Aled ReesProfessor of Endocrinology and Consultant EndocrinologistNeuroscience and Mental Health Research InstituteCardiff University, Dr Claire HighamConsultant EndocrinologistChristie Hospital NHS Foundation Trust, Lisa ShepherdEndocrinology ANP/NMP, NIHR Clinical Doctoral Research FellowDiabetes & Endocrinology, Birmingham Heartlands Hospital/Diabetes & Endocrine Centre, Louise BreenEndocrine Specialist Nurse, Advanced Nurse Practitioner for EndocrinologyGuy’s and St Thomas’ NHS Foundation Trust, Miriam AsiaSenior Endocrine Clinical Nurse SpecialistUniversity Hospitals Birmingham NHS Foundation Trust, Professor Wiebke Arlt MD DSc FRCP FMedSciWilliam Withering Chair of MedicineDirector, Institute of Metabolism and Systems Research (IMSR)College of Medical and Dental Sciences, University of Birmingham, Professor Simon PearceProfessor of EndocrinologyTranslational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Professor Peter Clayton MD FRCPCHHonorary Consultant Paediatrician, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust (MFT)Professor of Paediatric Endocrinology, Division of Developmental Biology & Medicine, FBMH, UoMChief Academic Officer, Health Innovation ManchesterClinical Director, Manchester Academic Health Science CentreDeputy Vice-President & Deputy Dean, Faculty of Biology, Medicine & Health, University of Manchester, Colin Perry PhD FRCP (UK)Consultant EndocrinologistAssociate Director of Medical EducationHonorary Associate Clinical ProfessorQueen Elizabeth University Hospital, Glasgow. [3] • Hydrocortisone provides the necessary endocrine hormonal requirements in symptomatic adrenal insufficiency and adrenal crisis. Infants should be seen at least every 3 to 4 months. To prevent adrenal crisis in all these situations, hydrocortisone needs to be administered and maintained as per above. 6. (1|⊕⊕⊕⊕), 3.2 We suggest using hydrocortisone (15–25 mg) or cortisone acetate (20–35 mg) in two or three divided oral doses per day; the highest dose should be given in the morning at awakening, the next either in the early afternoon (2 h after lunch; two-dose regimen) or at lunch and afternoon (three-dose regimen). Please encourage your patients to download and use this card. Treatment. If you have any queries regarding the card please contact the BSPED Clinical Committee, Download the BSPED Paediatric Steroid Treatment Card. (2|⊕⊕⚪⚪), 3.14 We suggest that pregnant patients with PAI be monitored for clinical symptoms and signs of glucocorticoid over- and under-replacement (eg, normal weight gain, fatigue, postural hypotension or hypertension, hyperglycemia), with at least one review per trimester. The Society for Endocrinology has more information about adrenal crisis. 1. Guidelines from Britain’s Society for Endocrinology on the emergency management of adrenal crisis, published in 2016, include the following diagnostic recommendations [ 17] : Adrenal insufficiency should be ruled out in any acutely ill patient with signs or symptoms potentially suggestive of acute adrenal insufficiency. (Ungraded best practice statement), 5.2 We suggest that PAI patients be evaluated annually for symptoms and signs of over- and under-replacement. Diagnostic measures should never delay treatment and if adrenal crisis is suspected, treatment should be initiated WITHOUT DELAY. The new NHS Steroid Emergency Card is a prompt to healthcare professionals when patients are admitted in crisis/as an emergency or when undergoing surgery/procedure, to ensure steroid treatment is given appropriately and promptly. identifying that the patient is at risk for adrenal insufficiency. Short-term administration of high doses of glucocorticoids is never harmful but failure to treat adrenal crisis can result in the death of the patient. Download the BSPED Paediatric Steroid Treatment Card for full guidance. Children can be given i.v. (2|⊕⊕⚪⚪), 5.4 We suggest patient education about increasing the dosage of glucocorticoids during intercurrent illness, fever, and stress. Those who have severe symptoms of the condition or adrenal crisis should undergo immediate treatment with medication until diagnostic test results are available. (Anesthesia, February 2020), Guidance during the initial phase of assessment and management of acute adrenal insufficiency (adrenal crisis) in adult patients. (Ungraded best practice statement), 4.5 We recommend that all patients should be equipped with a steroid emergency card and medical alert identification to inform health personnel of the need for increased glucocorticoid doses to avert or treat adrenal crisis and the need of immediate parenteral steroid treatment in the event of an emergency. All rights reserved. J C E M, Endocrine Society Guidelines Central Adrenal Insufficiency November 2016 . Omission of steroids in patients with AI, particularly during physiological stress such as an intercurrent illness or surgery, can also lead to an adrenal crisis. Patients who have a confirmed diagnosis of primary adrenal insufficiency should undergo glucocorticoid replacement therapy—typically with hydrocortisone (cortisol), the glucocorticoid hormone naturally produced by the adrenal glands. If the patient does not report a sustained, beneficial effect of replacement after 6 months, the DHEA should be discontinued. BSPED is keen to encourage uniform practice and improve the care of children and young people with adrenal insufficiency. Patients with a history compatible with adrenal suppression and presenting with features of adrenal crisis (i.e., hypotension, circulatory failure) should be treated urgently. Some patients are also uploading the pdf version as the lock screen on their mobile phones, to show health care professionals in a medical emergency. (2|⊕⚪⚪⚪), 3.10 If blood pressure remains uncontrolled, we suggest initiating antihypertensive treatment and continuing fludrocortisone. The number of individuals with primary and secondary adrenal insufficiency in Europe is estimated to be 20–50/100.000. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency, Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Peak cortisol levels below 500 nmol/L (18 μg/dL) (assay dependent) at 30 or 60 minutes indicate adrenal insufficiency. Contact adrenal@endocrinology.org for more information. Do not hesitate to give high doses of hydrocortisone to a pregnant woman; hydrocortisone is inactivated in the placenta and does NOT affect the unborn baby. ›. (Ungraded best practice statement), 3.15 We suggest that, based on the individual clinical course, an increase in hydrocortisone dose should be implemented, in particular during the third trimester. Patients should undergo a blood test to measure levels of adrenocorticotropic hormone (ACTH) – the hormone that signals the adrenal glands to produce cortisol – to establish a primary adrenal insufficiency diagnosis. Cortisol replacement. 5.1. Adrenal Insufficiency and Pain. This guideline aims to take the non-specialist through the initial phase of assessment … Free prescriptions. In patients with confirmed cortisol deficiency, a plasma ACTH >2-fold the upper limit of the reference range is consistent with PAI. The Endocrine Society recommends that acutely ill patients who have unexplained symptoms undergo diagnostic testing to rule out primary adrenal insufficiency. IV 0.9% normal saline infusion o Several litres may be required / 24-48 hours 3. 2021 Copyright Endocrine Society. Patients should keep these if advised by their medical team whilst implementation of the new steroid emergency card takes place. (2|⊕⊕⚪⚪), 3.19 In children with PAI, we suggest avoiding synthetic, long-acting glucocorticoids (eg, prednisolone, dexamethasone). (2|⊕⊕⚪⚪), 3.12 We suggest an initial period of 6 months of DHEA replacement. Explore a collection of top articles published in the Endocrine Society journals in 2020, selected on the basis of citations, downloads, and Altmetric score. (Endocrine Connections, September 2016, reviewed 2019 no change), Exogenous steroids, adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely, National Patient Safety Alert Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults. (Ungraded best practice statement), 3.21 In children with PAI and confirmed aldosterone deficiency, we recommend treatment with fludrocortisone (starting dosage, 100 μg/d). The optimal frequency of screening is unknown but can be done annually. The new card can be ordered through the usual NHS ordering mechanisms: Patients can also download a pdf version if they wish. (Ungraded best practice statement), 5.5 We suggest genetic counseling for patients with PAI due to monogenic disorders. This education includes identification of precipitating symptoms and signs and how to act in impending adrenal crisis. Stefan R. Bornstein (chair), Bruno Allolio, Wiebke Arlt, Andreas Barthel, Andrew Don-Wauchope, Gary D. Hammer, Eystein S. Husebye, Deborah P. Merke, M. Hassan Murad, Constantine A. Stratakis, and David J. Torpy. (1|⊕⊕⊕⚪), 3.9 In patients who develop hypertension while receiving fludrocortisone, we suggest reducing the dose of fludrocortisone. (2|⊕⚪⚪⚪), 3.4 We suggest against using dexamethasone for the treatment of PAI because of risk of Cushingoid side effects due to difficulties in dose titration. (2|⊕⊕⚪⚪), 3.3 As an alternative to hydrocortisone, we suggest using prednisolone (3–5 mg/d), administered orally once or twice daily, especially in patients with reduced compliance. Read the guidance on the prevention and emergency management of adult patients with adrenal insufficiency that accompanies the NHS Steroid Emergency Card. Adrenal crisis most commonly presents in children with known adrenal insufficiency who develop an intercurrent illness or injury (2|⊕⊕⚪⚪), 4.4 We suggest patient education concerning glucocorticoid adjustments in stressful events and adrenal crisis-prevention strategies including parenteral self- or lay-administration of emergency glucocorticoids. Guidance during the initial phase of assessment and management of acute adrenal insufficiency (adrenal crisis) in adult patients. • Adrenal crisis, associated with hypotension and disturbance of consciousness and/or mental state requires urgent treatment with hydrocortisone. (1|⊕⊕⚪⚪), 3.18 In children with PAI, we suggest treatment with hydrocortisone in three or four divided doses (total starting daily dose of 8 mg/m2body surface area) over other types of glucocorticoid replacement therapies, with doses adjusted according to individual need. (2|⊕⊕⊕⚪), 3.7 We recommend that all patients with confirmed aldosterone deficiency receive mineralocorticoid replacement with fludrocortisone (starting dose, 50–100 μg in adults) and not restrict their salt intake. Preparation for invasive diagnostic procedures such as colonoscopy and surgery requiring general anaesthesia are further risk factors for adrenal crises. Higher frequency regimens and size-based dosing may be beneficial in individual cases. (1|⊕⊕⊕⊕), 3.8 We recommend monitoring mineralocorticoid replacement primarily based on clinical assessment (salt craving, postural hypotension, or edema), and blood electrolyte measurements. For infants, we recommend sodium chloride supplements in the newborn period and up to the age of 12 months. Health care providers should conduct a corticotropin stimulation test to confirm the diagnosis when the patient’s condition allows. Full Guideline: Diagnosis and Treatment of Primary Adrenal Insufficiency Adrenal crisis can be a manifestation of previously undiagnosed adrenal failure. (2|⊕⚪⚪⚪), 2.4 We recommend measurement of plasma ACTH to establish PAI. Adrenal insufficiency (AI) is an often-unrecognised endocrine disorder, which can lead to adrenal crisis and death if not identified and treated. The sample can be obtained at the same time as the baseline sample in the corticotropin test or paired with the morning cortisol sample. July 11, 2020. + 3.0 Treatment of primary adrenal insufficiency in adults, Treatment and monitoring during childhood, + 4.0 Management and prevention of adrenal crisis in patients with PAI, Watch this expert CME/CE-certified presentation highlighting expert recommendations on the variety of continuous glucose monitoring devices for optimizing management of individual patients with type 1 and type 2 diabetes. (1|⊕⊕⊕⚪), 1.2 We recommend confirmatory testing with the corticotropin stimulation test in patients with clinical symptoms or signs suggesting PAI when the patient's condition and circumstance allow. People who have primary adrenal insufficiency and a confirmed aldosterone deficiency should undergo replacement therapy—typically with the synthetic hormone fludrocortisone—to maintain the body’s salt and water balance. Fluid replacement: Large volume of 5% dextrose in saline or 0.9% normal saline (1L/hr) should be infused immediately with continuous cardiac monitoring. These conditions include thyroid disease, diabetes mellitus, premature ovarian failure, celiac disease, and autoimmune gastritis with vitamin B12 deficiency. (2|⊕⊕⚪⚪), 3.13 We suggest monitoring DHEA replacement by measuring morning serum DHEA sulfate (DHEAS) levels (aiming at the midnormal range) before the intake of the daily DHEA replacement dose. Get updates on the latest breakthroughs, clinical practice guidelines, and career development opportunities, straight to your inbox. However, failure to treat a pregnant woman with adrenal insufficiency can result in death of mother and/or loss of the child. Adrenal insufficiency (AI) is a life-threatening condition requiring life-long glucocorticoid (GC) substitution therapy, as well as stress adaptation to prevent adrenal crises. (2|⊕⊕⚪⚪), 2.2 We suggest the low-dose (1 μg) corticotropin test for diagnosis of PAI only when the substance itself is in short supply. Society for Endocrinology. The Endocrine Society recommends that acutely ill patients who have unexplained symptoms undergo diagnostic testing to rule out primary adrenal insufficiency. (2|⊕⊕⚪⚪), 2.3 If a corticotropin stimulation test is not feasible, we suggest using a morning cortisol <140 nmol/L (5 μg/dL) in combination with ACTH as a preliminary test suggestive of adrenal insufficiency (until confirmatory testing with corticotropin stimulation is available). JCEM | February 2016 (September 2016) The Society for Endocrinology, the Association of Anaesthetists and the Royal College of Physicians have published new Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal … Learn more. Administer fluid bolus 20 mL/kg up to two times after administration of steroids and contact medical control if patient continues with hypotension. Treat as necessary. https://www.verywellhealth.com/adrenal-crisis-overview-4590108 Any underlying causes of the adrenal crisis, such as an infection, will also be treated. treatment at major surgical stress doses as recommended by guidelines, in all patients undergoing surgery for an adrenal tumor where there is evidence of ‘(possible) autonomous cortisol secretion’, i.e.
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