From the Guidelines
An adrenal crisis is a life-threatening medical emergency that occurs when the body doesn't produce enough cortisol, a vital hormone made by the adrenal glands, and requires immediate treatment with injectable hydrocortisone, typically 100mg intramuscularly or intravenously, as recommended by the most recent guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.
Definition and Causes
An adrenal crisis typically affects people with adrenal insufficiency, such as Addison's disease, and can be triggered by severe infections, trauma, surgery, vomiting, diarrhea, or missed steroid medication doses.
- The crisis occurs because cortisol is essential for maintaining blood pressure, blood sugar levels, and helping the body respond to stress, so when levels drop dramatically, multiple body systems begin to fail simultaneously.
- Symptoms of an adrenal crisis include severe weakness, confusion, abdominal pain, vomiting, diarrhea, low blood pressure, loss of consciousness, and potentially shock.
Prevention and Management
People with adrenal insufficiency should carry an emergency kit containing injectable hydrocortisone, wear a medical alert bracelet, and know how to increase their oral steroid dose during times of illness or stress, as recommended by the guidelines 1.
- The guidelines also recommend that patients with adrenal insufficiency should be given stress doses of hydrocortisone during the peri-operative period, and that the dose should be increased in patients taking drugs that induce CYP3A4, and in obese adults 1.
- It is essential to collaborate with the patient's endocrinologist when planning scheduled surgery and when caring for postoperative cases, especially for patients with multiple risk factors, such as age and comorbidities 1.
Key Recommendations
- Hydrocortisone 100mg should be given by intravenous injection at the start of surgery, followed by a continuous infusion of 200mg/24h, until the patient can take double their usual oral glucocorticoid dose by mouth 1.
- Patients with primary adrenal insufficiency require mineralocorticoid replacement, and dexamethasone is not adequate as glucocorticoid treatment in these patients due to its lack of mineralocorticoid activity 1.
- Children with adrenal insufficiency are more vulnerable to problems with glycaemic control and require frequent blood glucose monitoring, and can be treated with a bolus of hydrocortisone at induction of anaesthesia followed by an immediate continuous infusion of hydrocortisone 1.
From the Research
Definition and Overview
- Adrenal crisis is a life-threatening medical emergency that requires prompt recognition and treatment 2, 3, 4.
- It is associated with a high mortality rate unless appropriately recognized and treated in a timely manner 2.
- Adrenal crisis is an acute complication of adrenal insufficiency, which can occur in patients with established adrenal insufficiency or as the first presentation of the condition 3.
Precipitating Factors
- Gastrointestinal illness is a common precipitant for adrenal crisis 2.
- Infections, physical stress, surgical procedures, trauma, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress can also trigger an adrenal crisis 3, 4.
Symptoms and Presentation
- Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms, often leading to misdiagnosis and delayed treatment 3.
- Symptoms can develop rapidly, including weakness, nausea, muscle/joint pain, and drowsiness 4.
Treatment and Management
- Emergency treatment involves prompt recognition and administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities 3, 4.
- Treatment consists of immediate parenteral hydrocortisone (100 mg bolus) and subsequent continuous infusion until the underlying precipitating cause is cured and/or when regular supplementation can be continued 4.
Prevention and Education
- Prevention is centered around patient education, including stress dosing and parenteral glucocorticoid administration 3.
- Patients should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification 3.
- Educational programs and emergency cards can help patients, relatives, and spouses recognize and respond to an impending adrenal crisis 4.