Adrenal Insufficiency

Spot the at-risk patient - Anyone on chronic steroids, or recently weaned off them, may have a suppressed axis; a history of Addison's or pituitary disease is an obvious flag.

Stress-dose steroids - Supplement glucocorticoid to cover the surgical stress response in at-risk patients, with dose and duration scaled to the magnitude of surgery, and continue the patient's baseline steroid.

Recognize adrenal crisis - Unexplained hypotension not responding to fluids and vasopressors, especially with hyponatremia, hyperkalemia, or hypoglycemia, should be treated empirically with IV hydrocortisone — don't wait for confirmation.

Support hemodynamics - Resuscitate with fluids, correct electrolytes and glucose, and use vasopressors as a bridge while the steroid takes effect.

Electrolytes and glucose - Primary disease brings hyponatremia and hyperkalemia; monitor and correct them, and watch for hypoglycemia.

Postoperative vigilance - The stressed, healing patient can still crisis after surgery, so continue coverage and taper appropriately.

Adrenal insufficiency is deficient adrenal hormone production — cortisol, with or without aldosterone. It is primary (Addison's disease, adrenal gland destruction) or secondary (pituitary or hypothalamic disease, or — most commonly — suppression of the HPA axis by chronic exogenous steroids).

Cortisol is essential to the stress response; without it, the patient cannot mount the hemodynamic reserve surgery demands. The danger is adrenal crisis — hypotension refractory to fluids and pressors, precipitated by the stress of surgery, illness, or abrupt steroid withdrawal. Primary disease also brings mineralocorticoid loss, with hyponatremia, hyperkalemia, and volume depletion.