What is the immediate emergency management for a 31‑year‑old man with recent transsphenoidal pituitary surgery, secondary adrenal insufficiency, community‑acquired pneumonia, pre‑renal acute kidney injury, mild hyponatremia, hypomagnesemia, and a focal right‑upper‑limb clonic seizure progressing toward status epilepticus?

Immediate Emergency Management of Post-Transsphenoidal Surgery Patient with Suspected Adrenal Crisis and Seizures

Administer hydrocortisone 100 mg IV bolus immediately, followed by a continuous infusion of 200 mg over 24 hours, because this patient's altered mental status, hyponatremia, and secondary hypothyroidism after pituitary surgery indicate impending adrenal crisis—a life-threatening emergency that must not await laboratory confirmation. 1, 2

First-Hour Critical Interventions

Steroid Replacement (Priority #1)

• Give hydrocortisone 100 mg IV push now, then start 200 mg/24h continuous IV infusion (or 50 mg IV every 6 hours if infusion unavailable). 3, 1, 2
• Do not delay steroid administration for any reason—the patient's somnolence, behavioral changes, and hyponatremia post-pituitary surgery are cardinal early signs of adrenal insufficiency, which progresses to volume-resistant hypotension and death if untreated. 3, 1
• Never use dexamethasone in this patient with suspected secondary adrenal insufficiency, as it lacks mineralocorticoid activity. 3, 2

Seizure Management

• Administer lorazepam 4 mg IV slowly (2 mg/min) for the focal clonic seizure with altered consciousness. 4
• If seizures persist after 10-15 minutes, give an additional 4 mg lorazepam IV slowly. 4
• Ensure airway patency and have ventilatory support immediately available, as lorazepam causes respiratory depression, especially in heavily sedated post-ictal patients. 4
• Correct the hyponatremia cautiously (see below), as sodium of 133 mmol/L is a recognized seizure precipitant after neurosurgery. 1
• Check ionized calcium immediately—hypocalcemia can trigger seizures in pituitary dysfunction. 1

Fluid Resuscitation

• Infuse 0.9% normal saline at 1 L/hour for at least 2 liters total to treat pre-renal AKI (creatinine 190 µmol/L) and support blood pressure. 1, 2
• Do not restrict fluids—fluid restriction worsens both adrenal insufficiency and pre-renal AKI. 1
• Monitor for volume-resistant hypotension, which signals inadequate steroid replacement and requires immediate hydrocortisone dose escalation. 3

First 24-Hour Monitoring Protocol

Hemodynamic Surveillance

• Measure sitting and supine blood pressure every 2-4 hours to detect orthostatic hypotension, an early indicator of worsening adrenal insufficiency. 3, 1
• Recognize that somnolence, obtunded consciousness, and cognitive dysfunction are early adrenal crisis signs—test response to the 100 mg hydrocortisone bolus. 3

Laboratory Monitoring

• Check serum sodium, potassium, and glucose every 4-6 hours while on stress-dose steroids. 1
• Limit sodium correction to ≤8-10 mmol/L in the first 24 hours to prevent osmotic demyelination syndrome. 1
• Target glucose 7-10 mmol/L using insulin sliding scale—steroid-induced hyperglycemia is expected but easily managed. 1

Fever Management

• Continue stress-dose hydrocortisone despite the patient's fever and pneumonia—premature dose reduction precipitates adrenal decompensation. 3
• Do not attribute fever solely to infection; persistent pyrexia may indicate adrenal insufficiency itself. 3

Thyroid Hormone Management

• Continue levothyroxine 100 µg daily at the current dose—do not increase acutely, as excess thyroid hormone precipitates adrenal crisis when adrenal support is insufficient. 1
• The patient's low FT3 (2.04) and FT4 (0.52) with normal TSH (2.24) confirm sick euthyroid syndrome or secondary hypothyroidism, but acute thyroid hormone escalation is contraindicated during adrenal crisis. 1

Hyponatremia-Specific Considerations

• This patient's hyponatremia (133 mmol/L) likely represents SIADH, which occurs in 8-25% of post-transsphenoidal surgery patients, typically peaking on postoperative days 7-10. 5, 6, 7
• The combination of poor oral intake, pneumonia, and adrenal insufficiency creates multifactorial hyponatremia—the hydrocortisone infusion will address the adrenal component. 3, 8
• Plasma ADH is not suppressed during post-surgical hyponatremia, confirming SIADH pathophysiology. 7
• Monitor sodium daily through postoperative day 14, as delayed hyponatremia can occur even after initial improvement. 5, 7

Transition to Oral Therapy (48-72 Hours)

• Switch to oral hydrocortisone 15-25 mg daily in divided doses (e.g., 10 mg morning, 5 mg early afternoon, 5 mg evening) once the patient tolerates oral intake and is clinically stable. 1, 2
• Taper stress-dose regimen gradually over 3-5 days as clinical condition improves—abrupt cessation risks recurrent crisis. 1, 2
• Double the oral hydrocortisone dose for 48 hours after uncomplicated recovery, or up to one week if surgery was complicated. 3

Critical Pitfalls to Avoid

• Never delay hydrocortisone for confirmatory cortisol testing—adrenal crisis is a clinical diagnosis in this post-surgical context. 1, 2
• Never assume the patient's current blood pressure (110/70) excludes adrenal crisis—hypotension is a late, agonal sign. 3
• Never attribute altered mental status solely to post-ictal state—the prolonged sedation after lorazepam may mask ongoing adrenal insufficiency. 4
• Never stop stress-dose steroids while the patient remains febrile, haemodynamically unstable, or neurologically altered. 3

Post-Stabilization Endocrine Work-Up

• Perform comprehensive pituitary function testing (morning cortisol, ACTH, GH, prolactin, LH/FSH, testosterone) once acute illness resolves. 1
• Obtain pituitary-protocol MRI to evaluate the surgical bed for residual adenoma or complications. 1
• Arrange urgent endocrinology consultation for long-term hormone replacement optimization. 1
• Provide steroid-emergency identification card and medical-alert bracelet before discharge to ensure rapid treatment of future crises. 1, 9

Mortality Context

Adrenal crisis carries significant mortality risk, with overall mortality in adrenal insufficiency patients elevated 2.19-fold in men and 2.86-fold in women—aggressive early treatment is life-saving. 2, 10