Table 3.
Management of PAI in Specific Situations
| Condition | Suggested Action |
|---|---|
| Home management of illness with fever | Hydrocortisone replacement doses doubled (>38°C) or tripled (>39°C) until recovery (usually 2 to 3 d); increased consumption of electrolyte-containing fluids as tolerated |
| Unable to tolerate oral medication due to gastroenteritis or trauma | Adults, im or sc hydrocortisone 100 mg; children, im hydrocortisone 50 mg/m2 or estimate; infants, 25 mg; school-age children, 50 mg; adolescents, 100 mg |
| Minor to moderate surgical stress | Hydrocortisone, 25–75 mg/24 h (usually 1 to 2 d) |
| Children, im hydrocortisone 50 mg/m2 or hydrocortisone replacement doses doubled or tripled | |
| Major surgery with general anesthesia, trauma, delivery, or disease that requires intensive care | Hydrocortisone, 100 mg per iv injection followed by continuous iv infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h iv or im) |
| Children, hydrocortisone 50 mg/m2 iv followed by hydrocortisone 50–100 mg/m2/d divided q 6 h | |
| Weight-appropriate continuous iv fluids with 5% dextrose and 0.2 or 0.45% NaCl | |
| Rapid tapering and switch to oral regimen depending on clinical state | |
| Acute adrenal crisis | Rapid infusion of 1000 mL isotonic saline within the first hour or 5% glucose in isotonic saline, followed by continuous iv isotonic saline guided by individual patient needs |
| Hydrocortisone 100 mg iv immediately followed by hydrocortisone 200 mg/d as a continuous infusion for 24 h, reduced to hydrocortisone 100 mg/d the following day | |
| Children, rapid bolus of normal saline (0.9%) 20 mL/kg. Can repeat up to a total of 60 mL/kg within 1 h for shock. | |
| Children, hydrocortisone 50–100 mg/m2 bolus followed by hydrocortisone 50–100 mg/m2/d divided q 6 h | |
| For hypoglycemia: dextrose 0.5–1 g/kg of dextrose or 2–4 mL/kg of D25W (maximum single dose 25 g) infused slowly at rate of 2 to 3 mL/min. Alternatively, 5–10 mL/kg of D10W for children <12 y old | |
| Cardiac monitoring: Rapid tapering and switch to oral regimen depending on clinical state |
Abbreviation: D10W, 10% dextrose solution; D25W, 25% dextrose solution. [Adapted from B. Allolio: Extensive expertise in endocrinology: adrenal crisis. Eur J Endocrinol. 2015;172:R115–R124 (126), with permission. © Endocrine Society.]