Cushing's Syndrome: Symptoms, Causes, and Treatment - Medical Presentation

CUSHING’S SYNDROME Dr. Sibi Peter, PhD,RN,CCRN  FUNCTIONS OF ADRENAL CORTEX  Adrenal cortex steroid hormones  Glucocorticoids  Regulate metabolism and ↑ blood glucose  Critical to physiologic stress response  Minera...

CUSHING’S SYNDROME Dr. Sibi Peter, PhD,RN,CCRN  FUNCTIONS OF ADRENAL CORTEX  Adrenal cortex steroid hormones  Glucocorticoids  Regulate metabolism and ↑ blood glucose  Critical to physiologic stress response  Mineralocorticoids regulate  Sodium balance  Potassium balance  Androgen contributes to  Growth and development in both genders  Sexual activity in adult women 2  ETIOLOGY Excess of corticosteroids, particularly glucocorticoids Most common cause  Iatrogenic administration of exogenous corticosteroids 85% of endogenous cases due to ACTH- secreting pituitary tumor Other causes include  Adrenal tumors  Ectopic ACTH production in tumors outside hypothalamic-pituitary- adrenal axis  Lung and pancreas tumors 3  CLINICAL MANIFESTATIONS  Related to excess corticosteroids  Weight gain most common feature  Trunk (centripetal obesity)  Face (“moon face”)  Cervical area  Transient weight gain from sodium and water retention  Hyperglycemia  Glucose intolerance associated with cortisol-induced insulin resistance  Increased gluconeogenesis by liver 4  CLINICAL MANIFESTATIONS  Protein wasting  Catabolic effects of cortisol  Leads to weakness, especially in extremities  Protein loss in bones leads to osteoporosis, bone and back pain.  Loss of collagen  Wound healing delayed  Mood disturbances  Insomnia  Irrationality  Psychosis 5  CLINICAL MANIFESTATIONS  Mineralocorticoid excess may cause hypertension secondary to fluid retention.  Adrenal androgen excess may cause  Pronounced acne  Virilization in women  Feminization in men  Seen more commonly in adrenal carcinomas  Women: Menstrual disorders and hirsutism  Men: Gynecomastia and impotence  Purplish red striae on abdomen, breast, or buttocks 6  DIAGNOSTIC STUDIES  24-Hour urine for free cortisol  Levels above 80 to 120 mcg/day in adults indicate Cushing syndrome.  Low-dose dexamethasone suppression test used for borderline results of 24-hour urine cortisol  False-positives can occur with depression and with certain drugs.  Plasma cortisol levels may be elevated with loss of diurnal variation.  CT and MRI of pituitary and adrenal glands 7  COLLABORATIVE CARE  Primary goal is to normalize hormone secretion.  Treatment depends on cause.  Pituitary adenoma  Hypophysectomy  Surgical removal of tumor and/or radiation  Adrenal tumors or hyperplasia  Adrenalectomy 8  COLLABORATIVE CARE  If Cushing syndrome develops during use of corticosteroids  Gradually discontinue therapy  Decrease dose  Convert to an alternate-day regimen  Gradual tapering avoids potentially life-threatening adrenal insufficiency.  Long-term exogenous cortisol therapy is major risk factor.  Teach patients about medication use and to monitor for side effects. 9  NURSING IMPLEMENTATION  Preoperative care  Patient should be in optimal physical condition.  Control hypertension and hyperglycemia.  Hypokalemia must be corrected with diet and potassium supplements.  High-protein diet helps correct protein depletion.  Teaching depends on surgical approach.  Include information on postoperative care.  Nasogastric tube  Urinary catheter  IV therapy  Central venous pressure monitoring  Leg compression devices 10  NURSING IMPLEMENTATION  Postoperative care  Risk of hemorrhage is increased because of high vascularity of adrenal glands.  Manipulation of glandular tissue may release hormones into circulation.  BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations.  High doses of corticosteroids administered by IV during and several days after surgery  Report any significant changes in  BP  Respiration  Heart rate 11  NURSING IMPLEMENTATION  Postoperative care (cont’d)  Monitor fluid intake and output to assess for imbalances.  Critical period for circulatory instability ranges from 24 to 48 hours.  Morning urine levels of cortisol are measured to evaluate the effectiveness of surgery.  Bed rest until BP is stabilized after surgery  Meticulous care should be taken when accessing skin, circulation, or body cavities to avoid infection.  Normal inflammatory responses are suppressed.  Ambulatory and home care  Discharge instructions based on lack of endogenous corticosteroids  Wear Medic Alert bracelet always.  Avoid exposure to stress, extremes of temperature, and infection.  Lifetime replacement therapy is required for many patients after surgeries, giving them Addison’s disease. 12  Student Response Question An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to: 1. Prevent sodium and water retention after surgery. 2. Prevent clots from forming in the legs during recovery from surgery. 3. Provide substances to respond to stress after removal of the adrenal glands. 4. Stimulate the inflammatory response to promote wound healing. 13