Follow-up
Further Inpatient Care
- Admit to ICU as clinically indicated.
- Perform fluid resuscitation and hemodynamic monitoring as clinically indicated.
- Monitor serum electrolytes, magnesium, and glucose every 4-6 hours until stable.
- Search for precipitating cause of crisis (eg, infection, myocardial infarction, unreported exogenous steroid use within 12 mo, autoimmune disorder).
Further Outpatient Care
- Treat any underlying or precipitating disorder as clinically indicated.
- Carefully monitor growth and development in pediatric patients.
- Recommend medical tag or bracelet that alerts emergency personnel to adrenal gland insufficiency.
- If exposed to chickenpox, prophylaxis with varicella-zoster immune globulin is indicated.
- If exposed to measles, prophylaxis with immune globulin is indicated.
- Closely observe for reactivation of tuberculosis in patients with latent disease.
Inpatient & Outpatient Medications
- Taper steroid dose as outlined previously (see Medication).
Complications
- Immunosuppression
- Hypertension
- Salt retention
- Hypokalemia
- Weight gain
- Delayed wound healing
- Hyperglycemia
- Metabolic alkalosis
Prognosis
- Prognosis is the same as for patients without adrenal insufficiency if the condition is diagnosed and treated appropriately.
Patient Education
- Instruct patients regarding the importance of careful attention to health and fluid intake and to double maintenance doses when ill until medical attention is obtained.
- Avoid exposure to chickenpox or measles; if exposed, seek medical advice without delay.
- Notify physician or seek medical attention for persistent nausea and vomiting, fatigue, and abdominal pain.
- For excellent patient education materials, see eMedicine's Endocrine System Center and patient education article Anatomy of the Endocrine System.
Miscellaneous
Medicolegal Pitfalls
- Failure to obtain a comprehensive history, including medications, may lead to lack of recognition of potentially fatal, yet often preventable, secondary adrenocortical insufficiency.
Special Concerns
- Management of known or suspected primary or secondary adrenocortical insufficiency during stress includes the following:
- Acute illness - Hydrocortisone 100 mg IV every 6-8 hours for 4 doses, taper if patient stabilizes
- Perioperative - See the Table. Perioperative Steroid Therapy for Patients with Known Adrenal Insufficiency
Open table in new window
[ CLOSE WINDOW ]Table
Timing Hydrocortisone Hydrocortisone Fludrocortisone Routine daily … 20 mg PO at 8 am
10 mg PO at 4 pm0.1 mg PO at 8 am Day of operation 10 mg/h continuous infusion … … Postoperative day 1 5-7.5 mg/h continuous infusion … … Postoperative day 2 2.5-5 mg/h continuous infusion … … Postoperative day 3 2.5-5 mg/h continuous infusion or 40 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 4 2.5-5 mg/h continuous infusion or 40 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 5 … 40 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 6 … 20 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 7 … 20 mg PO at 8 am
10 mg PO at 4 pm0.1 mg PO at 8 am Timing Hydrocortisone Hydrocortisone Fludrocortisone Routine daily … 20 mg PO at 8 am
10 mg PO at 4 pm0.1 mg PO at 8 am Day of operation 10 mg/h continuous infusion … … Postoperative day 1 5-7.5 mg/h continuous infusion … … Postoperative day 2 2.5-5 mg/h continuous infusion … … Postoperative day 3 2.5-5 mg/h continuous infusion or 40 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 4 2.5-5 mg/h continuous infusion or 40 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 5 … 40 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 6 … 20 mg PO at 8 am
20 mg PO at 4 pm0.1 mg PO at 8 am Postoperative day 7 … 20 mg PO at 8 am
10 mg PO at 4 pm0.1 mg PO at 8 am
- In pregnancy, anticipated benefits must outweigh risks because no adequate human reproductive studies are available.
- Corticosteroids appear in breast milk.
- Corticosteroids can suppress growth and interfere with infant endogenous corticosteroid production.
- In primary adrenocortical insufficiency, glucocorticoid and mineralocorticoid replacement is required for life.
More on Adrenal Crisis |
| Overview: Adrenal Crisis |
| Differential Diagnoses & Workup: Adrenal Crisis |
| Treatment & Medication: Adrenal Crisis |
 Follow-up: Adrenal Crisis |
| Multimedia: Adrenal Crisis |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics:
Adrenal Insufficiency and Adrenal Crisis
Adrenal Disease and Pregnancy
Adrenal Hemorrhage [Endocrinology]
Adrenal Hemorrhage [Radiology]
Adrenal Insufficiency
Septic Shock
Shock, Septic
Clinical guidelines:
Managing asthma during pregnancy: recommendations for pharmacologic treatment.
National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency [U.S.]. 2005 Jan. 57 pages. NGC:004014
Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine.
Society of Critical Care Medicine - Professional Association. 2008 Jun. 13 pages. NGC:006612
Clinical trials:
Adrenal Insufficiency in Critical Emergencies in Digestive Diseases
Adrenal Insufficiency in Septic Shock
Adrenal Function in Critical Illness
Keywords
adrenal crisis, adrenal insufficiency, cortisol, gland adrenal, adrenal, adrenal gland, cortisol levels, adrenal supplements, acute adrenal crisis, acute adrenal insufficiency, acute adrenocortical insufficiency, Addisonian crisis, adrenal apoplexy, aldosterone, primary adrenocortical insufficiency, secondary adrenocortical insufficiency, bilateral massive adrenal hemorrhage, BMAH, endocrine disorder
