What is the treatment for an Addisonian crisis in a hospital setting?

Treatment of Addisonian Crisis in Hospital

Adrenal crisis should be treated immediately with intravenous hydrocortisone 100 mg bolus, followed by aggressive fluid resuscitation with 0.9% saline at 1 L over the first hour, without delaying for diagnostic confirmation. 1, 2, 3

Immediate Emergency Management

First-Line Treatment (Do Not Delay)

• Administer hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide necessary mineralocorticoid effect, eliminating the need for separate fludrocortisone during acute crisis 1, 2, 3
• Begin isotonic (0.9%) saline infusion at 1 L over the first hour to address severe volume depletion and hypotension 1, 2, 3
• Draw blood for cortisol, ACTH, electrolytes, creatinine, and glucose before treatment if possible, but never delay therapy waiting for results 1, 2, 3

Ongoing Hospital Management

• Continue hydrocortisone 100 mg every 6-8 hours (total 100-300 mg/day) either as continuous IV infusion or frequent IV/IM boluses until the patient recovers 1, 2, 3
• Maintain slower isotonic saline infusion for the following 24-48 hours, administering 3-4 liters total over 24 hours with frequent hemodynamic monitoring to avoid fluid overload 1, 2, 3
• Monitor serum electrolytes frequently to guide fluid management 2, 3
• Identify and treat the precipitating cause (e.g., infection, trauma) once treatment has been initiated 1, 3

Critical Clinical Pitfalls to Avoid

• Do not add fludrocortisone during acute crisis management—the high-dose hydrocortisone (100 mg) provides adequate mineralocorticoid activity 2, 3
• Do not use dexamethasone as it has no mineralocorticoid activity and is inadequate for primary adrenal insufficiency 1
• Never postpone treatment to obtain diagnostic confirmation—mortality increases with delayed intervention 2, 3, 4
• Do not assume absence of hyperkalemia excludes crisis—it is present in only 50% of cases, while hyponatremia occurs in 90% 2

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days to oral therapy once the precipitating illness permits and the patient can tolerate oral medications 2, 3
• Restart fludrocortisone when hydrocortisone dose falls below 50 mg per day, as lower doses no longer provide adequate mineralocorticoid effect 2
• Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or end-organ dysfunction 2, 3
• Provide gastric stress ulcer prophylaxis and consider low-dose heparin depending on severity of intercurrent illness 2, 3

Special Considerations

Perioperative Management

• In the event of unexplained fluid-unresponsive hypotension immediately prior to, during, or after surgery, adrenal insufficiency should be part of the differential diagnosis and an IV push dose of 100 mg hydrocortisone should be administered 1
• For major surgery, administer 100 mg hydrocortisone IM before anesthesia, and continue 100 mg every 6 hours until able to take oral medication 5

Pediatric Patients

• Administer initial normal saline fluid bolus of 10-20 ml/kg (maximum 1,000 ml) in children with hypotension 2
• Children are more vulnerable to hypoglycemia and require frequent blood glucose monitoring 1