From the Guidelines
Adrenal crisis is a life-threatening medical emergency characterized by severe hypotension, shock, and electrolyte abnormalities due to acute adrenal insufficiency, and immediate treatment involves rapid administration of hydrocortisone 100mg IV bolus followed by continuous infusion or repeated boluses (100mg every 6-8 hours), along with aggressive fluid resuscitation using normal saline, as recommended by the most recent guidelines 1.
Key Signs and Symptoms
The key signs and symptoms of adrenal crisis include:
- Sudden severe weakness, fatigue, and profound lethargy
- Severe abdominal pain, nausea, vomiting, and diarrhea
- Hypotension (blood pressure <90/60 mmHg) that may progress to shock
- Tachycardia, fever, confusion or altered mental status, and sometimes loss of consciousness
- Dehydration with decreased skin turgor, hyperpigmentation (particularly in primary adrenal insufficiency), and cool, clammy skin
- Laboratory findings include hyponatremia, hyperkalemia, hypoglycemia, and sometimes hypercalcemia
Importance of Prompt Treatment
Prompt recognition and treatment of adrenal crisis are crucial to prevent morbidity and mortality, as highlighted in a study published in 2020 1. The study emphasizes the importance of listening to well-informed adrenal patients and taking urgent action to avoid unnecessary deaths from this eminently treatable medical problem.
Recommendations for Treatment
The guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency recommend:
- Hydrocortisone 100 mg by intravenous (i.v.) injection at induction of anaesthesia, followed by a continuous infusion of hydrocortisone at 200 mg.24 h-1, until the patient can take double their usual oral glucocorticoid dose by mouth 1
- Collaboration with the patient's endocrinologist when planning scheduled surgery and when caring for postoperative patients, especially for patients with multiple risk factors (age, comorbidities) 1
Conclusion is not allowed, so the answer will continue without a conclusion section, and the response will be based on the provided evidence and guidelines.
The patient's history of glucocorticoid self-management, any previous episodes of adrenal crisis, and how practised they are at medication adjustments for illness, injury or postoperative recovery should be taken into account when planning treatment 1.
From the Research
Signs and Symptoms of Adrenal Crisis
The signs and symptoms of adrenal crisis can vary, but common symptoms include:
Triggers of Adrenal Crisis
Adrenal crisis can be triggered by various factors, including:
- Infection, often gastrointestinal 3
- Fever 3
- Trauma 3
- Acute psychological or physical stress 3
- Major stress, such as surgery or sepsis 4
Diagnosis and Treatment
Diagnosis of adrenal crisis is often challenging due to the non-specific symptoms, but it can be confirmed by specific testing such as the cosyntropin stimulation test 2. Treatment of adrenal crisis typically involves:
- Hydrocortisone administration, either intravenously or orally 2, 3, 4
- Intravenous fluid and glucose repletion 2
- Treatment of the underlying acute trigger 2
- Continuous intravenous hydrocortisone infusion may be preferred over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress 4
Potential Side Effects of Treatment
Treatment of adrenal crisis can lead to potential side effects, including:
- Hypertension, which can occur in some patients during treatment for adrenal crisis 5