What is the most important medication to give to a 30-year-old female patient with a history of ulcerative colitis (UC), adrenal disease, and current symptoms of septic shock, hyponatremia, hypoglycemia, hyperkalemia, acute kidney injury, non-anion gap metabolic acidosis, and eosinophilia?

Hydrocortisone IV is the Most Important Drug for Treating Adrenal Crisis in Septic Shock

The most important drug to be given for saving this patient is hydrocortisone 100mg IV bolus then 50mg every 6 hours (option C). This patient is presenting with a classic adrenal crisis in the setting of septic shock, requiring immediate corticosteroid replacement therapy 1.

Clinical Presentation Analysis

The patient presents with several critical findings that strongly suggest adrenal crisis:

• History of taking cortisone for "some adrenal disease" (indicating pre-existing adrenal insufficiency)
• Development of septic shock (trigger for adrenal crisis)
• Laboratory abnormalities classic for adrenal insufficiency:
  • Hyponatremia
  • Hypoglycemia
  • Hyperkalemia
  • Non-anion gap metabolic acidosis
  • Eosinophilia

These findings represent a life-threatening adrenal crisis precipitated by the stress of severe ulcerative colitis flare and subsequent septic shock.

Treatment Algorithm

1. First-line therapy: IV Hydrocortisone

   • Immediate administration of hydrocortisone 100mg IV bolus followed by 50mg every 6 hours 1
   • This provides both glucocorticoid and some mineralocorticoid activity needed to address the crisis

2. Supporting interventions:

   • Aggressive fluid resuscitation with isotonic saline to correct hypovolemia and hyponatremia
   • Vasopressor support as needed for shock (norepinephrine preferred) 1
   • Glucose administration to correct hypoglycemia
   • Treatment of underlying infection (broad-spectrum antibiotics)
   • Monitoring of electrolytes and blood glucose

3. Why other options are inferior:

   • Fludrocortisone (option A): While beneficial for mineralocorticoid replacement, it is oral only and insufficient as sole therapy in acute adrenal crisis 2
   • Dexamethasone (option B): Lacks mineralocorticoid activity needed to address hyperkalemia; not preferred in adrenal crisis 3
   • NaCl with calcium (option D): Addresses only electrolyte abnormalities without treating the underlying adrenal insufficiency

Evidence-Based Rationale

The Surviving Sepsis Campaign guidelines specifically recommend IV hydrocortisone for patients with septic shock who have adrenal insufficiency 1. The patient's history of cortisone treatment indicates chronic adrenal suppression, making her particularly vulnerable to adrenal crisis during the stress of severe infection.

Hydrocortisone at 200-300mg/day is the preferred corticosteroid in this scenario as it:

• Provides both glucocorticoid and mineralocorticoid effects
• Addresses hypotension refractory to fluids and vasopressors
• Corrects the metabolic derangements (hypoglycemia, hyponatremia, hyperkalemia)
• Can be given intravenously for rapid effect 1

Important Clinical Considerations

• Continuous infusion of hydrocortisone may provide better glycemic control than bolus dosing, but either approach is acceptable in the acute setting 4
• Do not delay corticosteroid administration while awaiting confirmatory testing 5
• Taper steroids when vasopressors are no longer required 1
• Monitor for hyperglycemia during treatment, as this is a common side effect of high-dose corticosteroids

Common Pitfalls to Avoid

1. Delaying corticosteroid administration while awaiting diagnostic tests
2. Using dexamethasone instead of hydrocortisone in adrenal crisis (dexamethasone lacks mineralocorticoid activity)
3. Relying solely on fludrocortisone (oral administration, delayed onset)
4. Failing to address the underlying infection and ulcerative colitis flare
5. Not considering etomidate-induced adrenal suppression if the patient was recently intubated 6

In this life-threatening scenario with clear evidence of adrenal crisis in a patient with known adrenal disease now experiencing septic shock, immediate IV hydrocortisone administration is the most important intervention to prevent mortality.