UMEM Educational Pearls

Category: Critical Care

Title: Adrenal Insufficiency in the Critically Ill

Keywords: adrenal insufficiency, hypotension, glucocorticoids, hydrocortisone (PubMed Search)

Posted: 1/1/2008 by Mike Winters, MD (Updated: 7/10/2020)
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Adrenal Insufficiency in the Critically Ill

  • Adrenal insufficiency (AI) is estimated to occur in up to 30% of critically ill patients
  • The most common causes of AI in the critically ill are SIRS and sepsis
  • In most cases of critically ill patients, AI is functional (i.e relative) - the adrenal response is insufficient to respond to the degree of stress
  • Diagnostic clues include hyponatremia, hyperkalemia, hypoglycemia (rare), and hemodynamic instability despite IVFs and vasopressors
  • Although still controversial, most feel that AI is present in critically ill patients with either a basal cortisol < 15 mcg/dl, an increase in < 9 mcg/dl after ACTH stimulation, or a random cortisol < 25 mcg/dl
  • IV hydrocortisone, methylprednisolone, and dexamethasone are the 3 glucocorticoids most commonly administered
  • Hydrocortisone is usually the preferred agent because it is the synthetic equivalent of cortisol (and has both glucocorticoid and mineralocorticoid activity)