Adrenal Insufficiency in Critically Ill Patients

Diagnosis and Treatment

The American College of Critical Care Medicine recommends hydrocortisone treatment for refractory shock requiring high-dose vasopressors, based on the ADRENAL and APROCCHSS trials, which documented earlier shock reversal and potential mortality benefit 1
The Surviving Sepsis Campaign recommends intravenous hydrocortisone <400 mg/day for ≥3 days for patients with septic shock not responsive to fluid and moderate to high-dose vasopressor therapy 6
Hydrocortisone 100 mg IV bolus should be administered immediately without waiting for diagnostic confirmation, followed by continuous infusion of 200 mg/24 hours or 50 mg IV every 6 hours 4, 5
Treatment should NEVER be delayed for diagnostic procedures—mortality is high if untreated 4, 5

Cancer immunotherapy can cause secondary adrenal insufficiency through direct hypothalamic-pituitary damage 4
Sepsis itself is the most common precipitant of adrenal crisis in patients with underlying adrenal insufficiency 3
Surgical episodes (perforated bowel requiring surgery) are documented precipitating factors for adrenal crisis 2, 3

Septic shock with documented hypocortisolism is associated with 26% mortality at 90 days when adrenal insufficiency is present versus 10% when absent 1
Relative adrenal insufficiency in critically ill patients is associated with higher risk of sepsis, septic shock, circulatory dysfunction, and new bacterial infections 1
Adrenal crisis has a documented mortality rate, with two deaths occurring during crisis in a prospective 2-year follow-up of 423 patients 2

Hyponatremia is present in 90% of newly diagnosed adrenal insufficiency cases 4
Anemia is a documented hematologic manifestation of adrenal crisis 3
The documented hypocortisolism in the context of septic shock represents inadequate adrenal response 1

The American College of Critical Care Medicine and the Surviving Sepsis Campaign recommend immediate treatment with hydrocortisone for patients with septic shock and relative adrenal insufficiency 1, 6
The guideline society recommends against using the ACTH stimulation test to identify which patients with septic shock should receive hydrocortisone 6