Adrenal Crisis in Critical Illness

Endocrine, Metabolic & Toxicology · ICU Decoded chapter 65 · Locked — free with a referral

By Dr Javed Akhtar · Last reviewed 3 October 2026

Cited to SCCM/ESICM 2017.

Key points

Adrenal crisis means immediate hydrocortisone: 100 mg IV bolus, then 200 mg/24 h in D5NS — never delay for a cosyntropin test.
Septic shock with an ongoing pressor requirement: hydrocortisone 200 mg/day.
Random cortisol <10 µg/dL during shock argues for CIRCI; ICU cosyntropin testing is still controversial.
Chronic steroid users need stress-dose coverage peri-op and in sepsis.
Taper hydrocortisone after clinical improvement — abrupt withdrawal can precipitate adrenal insufficiency.

Investigations

First tests: Sodium, potassium, bicarbonate, urea and creatinine, Blood glucose, Cortisol and ACTH.

Only if indicated: Blood cultures, ACTH stimulation test.

Repeat monitoring: Sodium, potassium, bicarbonate, urea and creatinine.

Management pathways in this chapter

Managing Relative Adrenal Insufficiency in Critical Illness

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The pathway step by step, with its decision points
Treatment orders with doses
Why and when to send each test

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