How should I manage peri‑procedural stress dosing and fluid therapy for a 40‑year‑old female with primary adrenal insufficiency undergoing renal artery embolization?

Peri-Procedural Management for Renal Artery Embolization in a 40-Year-Old Female with Addison's Disease

Administer hydrocortisone 100 mg IV bolus at procedure start, followed immediately by continuous IV infusion of 200 mg over 24 hours, and provide aggressive IV fluid resuscitation with isotonic saline. 1, 2

Glucocorticoid Stress Dosing Protocol

Intra-Procedural Management

• Give hydrocortisone 100 mg IV bolus at induction/procedure start 1, 2
• Immediately initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours 1, 3
  • This is superior to intermittent bolus dosing for maintaining physiologic cortisol levels during major stress 1, 3
  • Renal artery embolization qualifies as major/intermediate stress requiring full stress-dose coverage 1
• Alternative if continuous infusion unavailable: Hydrocortisone 50 mg IV or IM every 6 hours 1, 2

Post-Procedural Management

• Continue hydrocortisone 200 mg/24h IV infusion while NPO or if experiencing nausea/vomiting 1
• Once tolerating oral intake and hemodynamically stable: Switch to oral hydrocortisone at double her usual maintenance dose 1, 2
• Continue doubled oral dose for 48 hours minimum after uncomplicated procedure 1
• If complications occur: Continue doubled dose for up to 1 week 1
• Resume normal maintenance dosing (typically 15-25 mg daily in divided doses) after the stress period 2, 4

Fluid and Electrolyte Management

Aggressive Volume Resuscitation

• Administer 3-4 liters of isotonic saline or 5% dextrose in isotonic saline 5
• Initial infusion rate approximately 1 L/hour 5
• Patients with Addison's disease have both glucocorticoid AND mineralocorticoid deficiency, making them particularly susceptible to hyponatremia and volume depletion 1

Monitoring Requirements

• Monitor blood pressure (sitting and supine) for orthostatic hypotension 1
• Check serum sodium and potassium frequently 1, 5
• Watch for signs of fluid overload during aggressive resuscitation 5
• Monitor for early signs of adrenal crisis: malaise, somnolence, cognitive dysfunction, persistent hypotension despite fluids 1

Mineralocorticoid Considerations

• Hold fludrocortisone during high-dose hydrocortisone administration (doses >50 mg/day provide adequate mineralocorticoid activity) 5, 6
• Resume fludrocortisone 0.05-0.2 mg daily once hydrocortisone dose tapers below 50 mg/day 5, 4

Critical Pitfalls to Avoid

Never Delay Treatment

• Do not wait for cortisol levels or diagnostic confirmation before administering stress-dose steroids 2, 5
• Volume-resistant hypotension is a late sign of adrenal crisis—treat earlier symptoms immediately 1

Avoid Etomidate

• Do not use etomidate for sedation as it rapidly suppresses cortisol production by inhibiting 11-beta-hydroxylase 1
• If etomidate was used, maintain high suspicion for adrenal decompensation 1

Recognize Relative Adrenal Insufficiency

• Adrenal crisis can occur even with "normal" cortisol levels during physiologic stress 2, 5
• During major stress, cortisol requirements increase up to 5-fold (approximately 100 mg/day vs. normal 20 mg/day) 2, 5

Monitor for Persistent Pyrexia

• Do not attribute all fever to infection—adrenal insufficiency itself can cause pyrexia 1
• Do not reduce steroid supplementation while patient remains febrile 1

Patient Safety Measures

Emergency Preparedness

• Ensure patient has emergency hydrocortisone injection kit (100 mg) for self-administration 2, 7
• Verify medical alert bracelet/necklace and steroid emergency card are present 2, 7
• Educate patient/family on recognizing adrenal crisis signs and emergency injection technique 7

Post-Discharge Instructions

• Provide clear "sick day rules": Double oral hydrocortisone dose for any febrile illness or stress 2
• Instruct to seek immediate medical attention for persistent vomiting, severe illness, or inability to take oral medications 7

Rationale for This Approach

The continuous IV infusion method is strongly supported by pharmacokinetic data showing it is the only administration mode that persistently maintains cortisol concentrations in the physiologic stress range 3. Intermittent bolus dosing creates peaks and troughs that may leave patients vulnerable to adrenal crisis during trough periods 1, 3.

Renal artery embolization, while minimally invasive, represents significant physiologic stress requiring full stress-dose coverage 1. The combination of procedural stress, potential contrast exposure, and post-procedure pain all increase cortisol requirements 1.

Patients with primary adrenal insufficiency (Addison's disease) are at particularly high risk because they lack both glucocorticoid AND mineralocorticoid production, making aggressive fluid resuscitation equally critical as steroid replacement 1, 5.