Adrenal Crisis in Critical Illness

• 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.

Managing Relative Adrenal Insufficiency in Critical Illness

• Shock persisting despite intravenous fluids and vasopressors?
• Give hydrocortisone 50–75 mg IV q6h (200–300 mg/day)
• Hypotension now gone?
• Give corticosteroids for 5–7 days, then taper the dose according to clinical response
• In patients on chronic corticosteroid treatment, consider tapering toward their baseline steroid dose
• Keep up corticosteroid replacement · confirm adequate fluid resuscitation has occurred · rule out other causes of shock (see Chapter 1)
• Hold corticosteroids unless another condition requires them (see Chapter 10 on corticosteroids in ARDS)