Assessment and Management of Adrenal Insufficiency Before Etomidate Administration

Key Patient Populations at Risk for Adrenal Crisis

Patients with known Addison's disease or chronic steroid use are at high risk for adrenal crisis, and prophylactic steroids should be considered in these patients 1, 2
Patients with unexplained hypotension not responding to fluids or vasopressors may be at risk for adrenal crisis, and etomidate should be used with caution in these patients 1
Patients on long-term steroids for asthma, autoimmune diseases, or after transplant are at risk for adrenal insufficiency, and steroid supplementation should be considered before etomidate administration 1, 3
Patients who have undergone recent pituitary or adrenal surgery may be at risk for adrenal insufficiency, and prophylactic steroids should be considered in these patients 1, 4
Patients with septic shock not improving despite adequate resuscitation may be at risk for adrenal crisis, and etomidate should be used with caution in these patients 1, 5

Persistent hypotension despite fluids/pressors is a sign of potential adrenal crisis 1
Severe weakness, fatigue, collapse, and altered mental status are symptoms that may indicate adrenal insufficiency 1, 6
Nausea, vomiting, abdominal pain, and hyperpigmentation are also potential signs of adrenal crisis 1
Hyponatremia, hyperkalemia, hypoglycemia, and low bicarbonate/mild metabolic acidosis are laboratory findings that may indicate adrenal insufficiency 1, 6

The American Society of Anesthesiologists recommends administering hydrocortisone 100 mg IV bolus immediately before etomidate administration in high-risk patients 1, 6
Alternative steroid regimens, such as dexamethasone 4-8 mg IV, may be considered in patients with uncertain diagnosis 1
Clinical judgment is required regarding steroid supplementation in patients receiving a single induction dose of etomidate, according to the American College of Critical Care Medicine 2
Patients taking drugs that induce CYP3A4 or obese adults may require higher doses of hydrocortisone due to faster metabolism or increased volume of distribution, as recommended by the Society of Critical Care Medicine 2

The Society of Critical Care Medicine guidelines acknowledge etomidate's effect on adrenal function but note that most studies show no significant difference in mortality between etomidate and other induction agents 7