Acute Adrenal Crisis Following Etomidate Administration in a Patient With Preexisting Adrenal Insufficiency

We present the case of a 79-year-old male with iatrogenic adrenal insufficiency on chronic hydrocortisone who presented with acute hypoxic respiratory failure due to severe bilateral pneumonia. He underwent rapid sequence intubation with IV etomidate and rocuronium. Within hours, he developed worsening hypotension, progressing to pulseless electrical activity cardiac arrest. Return of spontaneous circulation was achieved after two rounds of CPR and epinephrine. Despite vasopressor support, hypotension persisted until a 100 mg IV bolus of hydrocortisone was administered, leading to rapid hemodynamic stabilization. He was subsequently transitioned to stress-dose steroids. Given his underlying adrenal insufficiency, recent etomidate use, and sepsis, adrenal crisis was identified as the likely cause of his refractory shock and arrest. This case highlights the risk of etomidate-induced adrenal suppression in vulnerable patients and underscores the importance of administering corticosteroids prior to etomidate use, particularly in those with adrenal dysfunction or suspected sepsis.