Comprehensive Guide to Acute Adrenal Crisis Management


  • Acute adrenal crisis is a life-threatening condition.
  • Requires careful management and awareness from anesthesia residents.


  • Sudden deficiency of cortisol and aldosterone.
  • Often due to primary adrenal insufficiency, secondary adrenal insufficiency, or iatrogenic causes.
  • Cortisol is critical in regulating blood pressure, glucose metabolism, and stress response.


  • Various causes, including:
    • Underlying adrenal insufficiency (Addison’s disease)
    • Abrupt cessation of exogenous glucocorticoid therapy
    • Adrenal hemorrhage or infarction
    • Severe stressors like surgery, trauma, or infection.

Clinical Presentation and Diagnosis:

  • Symptoms include:
    • Profound hypotension
    • Tachycardia
    • Dehydration
    • Altered mental status
    • Electrolyte imbalances (hyperkalemia, hyponatremia).
  • Diagnosis relies on:
    • Clinical suspicion
    • Laboratory evaluation (low cortisol levels)
    • Adrenal imaging to identify the underlying cause.

Preoperative Assessment:

  • Perform a thorough preoperative assessment:
    • Review medical history
    • Medications (especially glucocorticoid use)
    • Comprehensive physical examination.
  • Consider laboratory tests (baseline cortisol levels) to gauge adrenal function.

Preoperative Management:

  • Prompt initiation of stress-dose glucocorticoid therapy (usually hydrocortisone).
  • Adequate fluid resuscitation to address hypovolemia.
  • Close monitoring of:
    • Hemodynamic parameters
    • Electrolytes
    • Blood glucose levels.

Anesthesia Considerations:

  • Choose anesthetic agents and techniques that:
    • Minimize the stress response
    • Maintain hemodynamic stability.
  • Recognize potential drug interactions with glucocorticoid replacement therapy.
  • Be prepared to use vasopressors and inotropes judiciously to manage hypotension.

Complications and Mitigation Strategies:

  • Awareness of potential complications:
    • Cardiovascular collapse
    • Electrolyte disturbances
    • Hyperglycemia.
  • Mitigation strategies include:
    • Vigilant monitoring
    • Prompt intervention
    • Effective communication with the surgical team for coordinated care.

Postoperative Care:

  • Includes continued glucocorticoid supplementation to address the patient’s stress response.
  • Monitor for complications:
    • Recurrent adrenal crisis
    • Electrolyte imbalances
    • Cardiovascular instability.
  • Ensure a seamless transition to ongoing care.


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