Adrenal Crisis

Treat suspected adrenal crisis as a time-critical glucocorticoid emergency. Give hydrocortisone 100 mg IV or IM immediately in adults, then arrange emergency transport or inpatient management; guidance emphasizes that emergency hydrocortisone has no overdose risk in this setting. nice org uk+2nice org ukNG243 Adrenal insufficiency: identification and managementnice org uk[PDF] Adrenal insufficiency: identification and management - NICEnice org ukAdrenal insufficiency: identification and management - NICE

Establish intravenous access, initiate cardiac monitoring, and assess blood pressure, mental status, serum glucose, volume status, and electrolytes while hydrocortisone is being administered. Hypoglycemia, hypotension, and dehydration require concurrent correction rather than sequential management. BMJ+1BMJEmergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance | Archives of Disease in Childhoodnice org ukAdrenal insufficiency: identification and management

If presentation is a new suspected adrenal insufficiency, draw diagnostic samples before hydrocortisone only when this can be done immediately. A delay in glucocorticoid treatment to obtain laboratory results is inappropriate in an unstable patient. BMJ+2BMJEmergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance | Archives of Disease in ChildhoodBMJBritish Society for Paediatric Endnice org uk[PDF] Adrenal insufficiency: identification and management - NICE

Start 0.9% sodium chloride intravenously and titrate ongoing infusion to hemodynamic parameters and electrolyte status until the patient is hemodynamically stable. Continue frequent reassessment of blood pressure, perfusion, mental status, urine output, sodium, potassium, and glucose during early treatment. nice org uknice org ukAdrenal insufficiency: identification and management - NICE

Measure and treat hypoglycemia at presentation, especially in children and in patients with impaired consciousness, seizures, or poor oral intake. Hydrocortisone, volume replacement, and glucose correction should proceed concurrently. BMJ+1BMJEmergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance | Archives of Disease in ChildhoodBMJBritish Society for Paediatric End

Continue parenteral stress-dose hydrocortisone during the acute phase. Once the patient is clinically stable and the underlying trigger has resolved or is controlled, transition to at least 40 mg/day oral hydrocortisone in 2 to 4 divided doses, or at least 10 mg/day oral prednisolone in 1 to 2 divided doses, until recovery is established. nice org uknice org ukAdrenal insufficiency: identification and management - NICE

For a first presentation of suspected adrenal insufficiency or crisis, obtain serum cortisol and plasma ACTH before hydrocortisone when feasible. Add serum glucose, urea and electrolytes, renin, aldosterone, and—when congenital adrenal hyperplasia is in the differential—17-hydroxyprogesterone and urine steroid profile. BMJ+1BMJEmergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance | Archives of Disease in ChildhoodBMJBritish Society for Paediatric End

The acute sample supports later classification but should not be used to defer resuscitation. Elevated endogenous ACTH with impaired adrenal reserve supports primary adrenal insufficiency, whereas the cosyntropin response alone has limited sensitivity for secondary adrenal insufficiency, particularly with recent-onset ACTH deficiency. PubMed+1PubMedAdrenocorticotropic Hormone (Cosyntropin) Stimulation Test - StatPearls - NCBI BookshelfScienceDirectCosyntropin - an overview | ScienceDirect Topics

After stabilization, use a cosyntropin stimulation test when basal cortisol is indeterminate, commonly 5–10 micrograms/dL. Obtain baseline, 30-minute, and 60-minute cortisol values, and interpret the peak using the performing laboratory's assay-specific cutoff. PubMed+1PubMedAdrenocorticotropic Hormone (Cosyntropin) Stimulation Test - NCBIPubMedAdrenocorticotropic Hormone (Cosyntropin) Stimulation Test - StatPearls - NCBI Bookshelf

Continue stress-dose hydrocortisone until the patient is clinically stable and the precipitating cause has resolved or is controlled. In adults, the recommended oral bridge is at least 40 mg hydrocortisone daily in 2 to 4 divided doses or at least 10 mg prednisolone daily in 1 to 2 divided doses before return to the patient's maintenance regimen. nice org uknice org ukAdrenal insufficiency: identification and management - NICE

Do not administer fludrocortisone during high-dose hydrocortisone treatment when total hydrocortisone exceeds 50 mg per 24 hours, because hydrocortisone provides sufficient mineralocorticoid effect at those doses. Reassess mineralocorticoid replacement as hydrocortisone is tapered below this exposure in primary adrenal insufficiency. NEJMNEJMAdrenal Crisis

For children recovering from adrenal crisis, observe until oral hydrocortisone at sick-day dosing is tolerated. Pediatric sick-day oral hydrocortisone is approximately 30 mg/m2/day in four divided doses, with guidance also describing 30–50 mg/m2/day in three or four doses followed by gradual reduction to maintenance therapy. BMJ+1BMJEmergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance | Archives of Disease in ChildhoodBMJBritish Society for Paediatric End

Identify and treat the precipitating cause during admission while maintaining stress-dose glucocorticoid therapy. Continue endocrine team involvement throughout hospitalization to guide etiologic evaluation, replacement adjustment, and safe transition to outpatient care. nice org uknice org ukAdrenal insufficiency: identification and management - NICE

Before discharge, ensure that patients with adrenal insufficiency have access to an emergency management kit containing IM hydrocortisone and that the patient or a caregiver can administer it when adrenal crisis is suspected. IM hydrocortisone can be self-administered or administered by nonclinicians in an emergency. nice org uk+1nice org uk[PDF] Adrenal insufficiency: identification and management - NICEnice org ukAdrenal insufficiency: identification and management - NICE

For established pediatric adrenal insufficiency, intercurrent illness requiring sick-day treatment should prompt immediate-release oral hydrocortisone in divided doses; children receiving twice-daily modified-release hydrocortisone should be switched to immediate-release hydrocortisone during the sick-day episode. BMJBMJEmergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance | Archives of Disease in Childhood