Acute Adrenal Insufficiency

During an acute adrenal crisis, the immediate treatment goals are to correct volume depletion, manage hypoglycemia, and provide glucocorticoid replacement. V°lume depletion and hypoglycemia can be corrected by giving2large volumes (approximately 2-3 L) of IV normal saline and 5% dextrose solution. Glucocorticoid replacement can be accomplished by administering IV hydrocortisone, starting at a dose of 100 mg every 6 to 8 hours for 24 hours, increasing to 200 mg to 400 mg/day if complications occur, or decreasing to 50 mg every 6 to 8 hours after achieving hemodynamic stability. The hydrocortisone dose can then be tapered to a maintenance dose by the fourth or fifth day and fludrocortisone can be added if needed.2

^^ Patients with known adrenal insufficiency should be educated regarding the need for additional glucocorticoid replacement and prompt medical attention during periods ofexcessive physiologic stress. Although the dosage of glucocorticoid is generally individualized, a common recommendation is to double the maintenance dose of hydrocortisone if the patient experiences fever, or undergoes invasive dental or diagnostic procedures.5 Patients who experience vomiting or diarrhea may not adequately absorb oral glucocorticoids and may benefit from parenteral therapy until symptoms resolve. Prior to major surgery, additional glucocorticoid replacement (higher dose and parenteral route) must be given to prevent adrenal crisis. A sample protocol is as follows :

• Correct electrolytes, blood pressure, and fluid status as necessary.

• Give 100 mg of hydrocortisone sodium phosphate or hydrocortisone sodium succin-ate intramuscularly (also, make sure this is readily available to the operating room).

• Give 50 mg of hydrocortisone intramuscularly or IV in the recovery room and then every 6 hours for the first 24 hours.

• If the patient is hemodynamically stable, reduce dosage to 25 mg every 6 hours for 24 hours and then taper to maintenance dosage over 3 to 5 days.

• Resume previous fludrocortisone dose when the patient is taking oral medications.

• Maintain or increase hydrocortisone dosage to 200 mg to 400 mg/day if fever, hypotension, or other complications occur.

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