ICU · Endocrine
Adrenal insufficiency and Addisonian crisis
Also known as Addisonian crisis · Adrenal crisis · Critical illness-related corticosteroid insufficiency (CIRCI) · Relative adrenal insufficiency
Adrenal crisis is a life-threatening state of glucocorticoid deficiency. Presents with hypotension (refractory to catecholamines), abdominal pain, nausea/vomiting, confusion, hyponatraemia, hyperkalaemia, hypoglycaemia. Precipitated by: stress (infection, surgery, trauma) in patients with underlying adrenal insufficiency (primary = Addison's; secondary = pituitary; tertiary = exogenous steroids). Treatment: IMMEDIATE hydrocortisone 100 mg IV stat then 50 mg IV Q6H (or 200 mg/24h infusion) — do NOT wait for cortisol/ACTH results. IV fluids (normal saline + dextrose for hypoglycaemia). Treat precipitant. Identify type: primary (high ACTH, hyperpigmentation, hyperkalaemia) vs secondary/tertiary (low ACTH, no hyperpigmentation, normal K).
Checked against its sources on 3 Sept 2026
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Red flags
- Give hydrocortisone IMMEDIATELY — do NOT wait for cortisol/ACTH results in suspected crisis
- Patients on chronic steroids have suppressed HPA axis — give STRESS DOSE hydrocortisone for any critical illness
- Patients on etomidate (intubation induction) can develop adrenal suppression — single dose causes transient CIRCI
- Hyponatraemia + hyperkalaemia + hypotension = Addisonian crisis until proven otherwise
Meet the patient
A 64-year-old woman with rheumatoid arthritis on prednisolone 15 mg daily for four years arrives in septic shock from a pneumonia. Three litres of crystalloid and noradrenaline at 0.5 mcg/kg/min hold her MAP at 58; lactate 4.8, sodium 126, potassium 4.9, glucose 3.2. She is cool, mottled and oliguric — and her pressure will not climb.[3] The question every registrar gets asked at that bedspace: "Why is she not responding, and what do you give in the next five minutes?" The answer is the same word every time — hydrocortisone — and the rest of this topic is why, how much, and how not to be caught by the three traps (the missing stress dose, the etomidate given upstairs, the adrenal haemorrhage no one scanned for).[1]
References21ShowHide
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- [3]Broersen LH, Pereira AM, Jørgensen JO, et al. Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab, 2015.PMID 25844620
- [4]Bowley J, Shallish S, Smyth N, et al. Adrenal insufficiency following systemic glucocorticoid therapy: a systematic review and meta-analysis. Eur J Intern Med, 2026.PMID 41521083
- [5]Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA, 2002.PMID 12186604
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- [7]Venkatesh B, Finfer S, Cohen J, et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med, 2018.PMID 29347874
- [8]Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med, 2018.PMID 29490185
- [9]Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med, 2017.PMID 28938253
- [10]Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet, 2009.PMID 19573904
- [11]Chan CM, Mitchell AL, Shorr AF Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis. Crit Care Med, 2012.PMID 22971586
- [12]Bruder EA, Ball IM, Ridi S, et al. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev, 2015.PMID 25568981
- [13]Barthel A, Benker G, Berens K, et al. An Update on Addison's Disease. Exp Clin Endocrinol Diabetes, 2019.PMID 30562824
- [14]Meade-Aguilar JA, Figueroa-Parra G, Yang JX, et al. Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review. Clin Immunol, 2024.PMID 38244823
- [15]Hahner S, Spinnler C, Fassnacht M, et al. High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency: a prospective study. J Clin Endocrinol Metab, 2015.PMID 25419882
- [16]Yo WS, Toh LM, Brown SJ, et al. How good is a morning cortisol in predicting an adequate response to intramuscular synacthen stimulation? Clin Endocrinol (Oxf), 2014.PMID 24274236
- [17]Lee SC, Baranowski ES, Sakremath R, et al. Hypoglycaemia in adrenal insufficiency. Front Endocrinol (Lausanne), 2023.PMID 38053731
- [18]Berlot G, Tomasini A, Zanchi S, et al. Waterhouse-Friderichsen syndrome following a dog bite in an asplenic patient: case report and review of the literature. Int J Emerg Med, 2023.PMID 36823575
- [19]Wolff ASB, Kucuka I, Oftedal BE Autoimmune primary adrenal insufficiency - current diagnostic approaches and future perspectives. Front Endocrinol (Lausanne), 2023.PMID 38027140
- [20]Bridwell RE, April MD Adrenal Emergencies. Endocrinol Metab Clin North Am, 2026.PMID 41656028
- [21]Denny N, Raghunath S, Bhatia P, Abdelaziz M Rifampicin-induced adrenal crisis in a patient with tuberculosis: a therapeutic challenge. BMJ Case Rep, 2016.PMID 27899384