IV Hydrocortisone Administration in Adrenal Crisis

Immediate Bolus and Continuous Infusion

In patients with suspected or confirmed adrenal crisis, give an immediate 100 mg hydrocortisone IV bolus (push) followed without delay by a continuous infusion of 200 mg over the next 24 hours until hemodynamic stability is achieved. 1
The 100 mg bolus can be delivered over several minutes as a direct push through established IV access. 2
Do not postpone the hydrocortisone bolus to wait for diagnostic blood work; if possible, obtain cortisol and ACTH samples before treatment but administer the drug as soon as venous access is secured. 1

Initiate aggressive crystalloid resuscitation with 0.9 % normal saline; give an initial 5–10 mL/kg within the first 5 minutes, with total volumes up to 7 L potentially required in adult patients. 2
Avoid lactated Ringer’s solution for the initial fluid bolus because it may exacerbate metabolic acidosis; use only isotonic saline. 2
In patients with underlying congestive heart failure or chronic kidney disease, monitor fluid status closely during aggressive resuscitation to prevent volume overload. 2

A 100 mg hydrocortisone bolus provides 4–5 times the usual daily replacement dose, delivering supraphysiologic glucocorticoid concentrations needed to suppress the life‑threatening inflammatory cascade of adrenal crisis. 3

For minor surgical procedures, a single 100 mg IV or IM dose of hydrocortisone at induction is sufficient; thereafter double the oral glucocorticoid dose for the next 24 hours. 1
For major surgery, administer 100 mg hydrocortisone at induction and repeat 100 mg every 6 hours for 24–48 hours, then transition to a doubled oral maintenance dose. 1