Emergency Hydrocortisone in Adrenal Insufficiency .pdf

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Original filename: Emergency Hydrocortisone in Adrenal Insufficiency.pdf
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Emergency Hydrocortisone for Adrenal Insufficiency
I am a patient with adrenal insufficiency. I have explained to you that I need
additional hydrocortisone in an emergency, delivered through injection or
intravenously. I have also explained that failure to administer emergency
hydrocortisone is life threatening and may result in a negative outcome.
Current clinical guidelines published in the Journal of Clinical Endocrinology and
Metabolism provide clear recommendations for emergency hydrocortisone
treatment for adrenal insufficient patients. Please read excerpt provided before
signing.
“We recommend that patients with suspected adrenal crisis should be treated with an
immediate parenteral injection of 100 mg (50 mg/m2 for children) hydrocortisone,
followed by appropriate fluid resuscitation, and 200 mg (50-100 mg/m2 for children) of
hydrocortisone/24 hours via continuous IV therapy or 6 hourly injections. In acutely sick
patients with clinical signs and symptoms, treatment should not be delayed while waiting
for test results. Delayed treatment of severely ill patients will result in increased
morbidity and mortality. A single baseline ACTH and cortisol test may be required for
diagnosis but only if it is safe to do so. Confirmatory testing may be performed after
treatment by the temporary withdrawal of steroids once the patients’ condition is stable.”
Diagnosis and Treatment of Primary Adrenal Insufficiency, Clinical Practice Guideline. JCEM
January 2016

By signing below you are acknowledging that you have been made aware of these
recommendations but are refusing to administer treatment.
Patient’s name: ________________________________ DOB: ________________

Signed: _____________________________________________
(To be signed by the medical personnel refusing treatment)

Print name: _________________________________________

Date: ______________________________


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