Acute Adrenal Insufficiency Management

Diagnosis and Treatment

The American College of Anaesthesiologists recommends hydrocortisone 100 mg IV as a bolus, followed by a continuous infusion of 200 mg/24h for acute adrenal insufficiency, with immediate fluid resuscitation to prevent mortality 1, 2
In primary adrenal insufficiency, the Endocrine Society suggests specifically looking for cutaneous hyperpigmentation and a desire for salt, and notes that secondary adrenal insufficiency presents with low cortisol but preserved aldosterone production 3, 1

The American College of Endocrinology recommends hydrocortisone 15-25 mg/day in divided doses to mimic the circadian rhythm, with the addition of fludrocortisone 0.05-0.3 mg/day for mineralocorticoid replacement in primary insufficiency 4, 1

For major surgery in adults, the American Society of Anesthesiologists recommends hydrocortisone 100 mg IV at induction, followed by a continuous infusion of 200 mg/24h until oral intake is resumed, then doubling the usual oral dose for 48 hours 3, 1, 4
In pediatric patients undergoing major surgery, the Pediatric Endocrine Society suggests hydrocortisone 2 mg/kg IV at induction, followed by a weight-based continuous infusion, and doubling the usual oral dose for 48 hours postoperatively 3, 5, 1

The American College of Obstetricians and Gynecologists notes that pregnant women may require higher maintenance doses from the 20th week of gestation 1
The Pediatric Endocrine Society recommends that children be closely monitored for glycemic control, as they are more vulnerable to glycemic problems than adults 1

The Endocrine Society emphasizes the importance of patient education on increasing glucocorticoids during acute illnesses, and prescribing injectable hydrocortisone for emergency use 1
The American College of Endocrinology suggests that all patients should receive a steroid card or medical alert bracelet indicating their diagnosis and need for hydrocortisone 1