Management of Adrenal Insufficiency with Hypotension and Elevated Trough Cortisol

Initial Management

Administer hydrocortisone 100 mg intravenously immediately, followed by continuous infusion of 200 mg/24 hours, as recommended by the American Society of Anesthesiologists, for patients with symptoms of adrenal insufficiency including hypotension, despite elevated trough cortisol levels 1, 2, 3
Provide rapid volume resuscitation with 3-4 L isotonic saline or 5% dextrose in isotonic saline with an initial infusion rate of approximately 1 L/hour, to manage hypotension in patients with adrenal insufficiency 3
Monitor hemodynamic parameters and serum electrolytes frequently to avoid fluid overload in patients with adrenal insufficiency 3
Consider ICU or high-dependency unit admission depending on severity of adrenal insufficiency 3

Adrenal crisis symptoms and signs can occur in physiologically stressed patients while plasma cortisol levels are normal or even high, recognized as "relative adrenal insufficiency", according to the American College of Anesthesiologists 1, 2
During physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg, as stated by the Endocrine Society 4
Patients with comorbidities, such as asthma and diabetes, are more vulnerable to adrenal crisis, as reported by the American Diabetes Association and the American Thoracic Society 1, 2

Once hemodynamically stable and able to take oral medications, transition to oral hydrocortisone at double the usual maintenance dose, as recommended by the American College of Anesthesiologists, to manage adrenal insufficiency 1, 2
Continue doubled oral dose for 48 hours to 1 week, depending on clinical recovery, according to the Endocrine Society 1, 2
If patient remains unstable, continue intravenous hydrocortisone infusion, as stated by the American Society of Anesthesiologists 2
Ensure mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg daily) is restarted when hydrocortisone dose falls below 50 mg/day for patients with primary adrenal insufficiency, as recommended by the American College of Physicians 3

Assess blood pressure, heart rate, and clinical symptoms frequently during initial resuscitation, to monitor response to treatment in patients with adrenal insufficiency, as recommended by the American Heart Association 3

Educate patient on self-management of their condition, including emergency hydrocortisone injection kit (100 mg) for self-administration during emergencies, as recommended by the American College of Physicians 3
Ensure patient wears medical alert identification and carries a steroid alert card, to prevent future episodes of adrenal crisis, as stated by the Endocrine Society 5

Never delay treatment of suspected adrenal crisis for diagnostic procedures, as emphasized by the American College of Emergency Physicians 5
Adrenal crises requiring hospital treatment occur in approximately 6-8 per 100 patient-years among patients with adrenal insufficiency, according to the American Journal of Medicine 1
Mortality risk is significantly higher in patients with adrenal insufficiency, with a risk ratio of 2.19 for men and 2.86 for women, as reported by the National Institutes of Health 1
In the only prospective study to date, the incidence of adrenal crisis was 8.3 per 100 replacement years, with two deaths during a 2-year follow-up, as stated by the Journal of Clinical Endocrinology and Metabolism 1