IV Hydrocortisone Dosing
For adults with adrenal crisis, give 100 mg IV hydrocortisone immediately, followed by 200 mg/24 hours (either as continuous infusion or 50 mg every 6 hours); for children, give 50 mg/m² IV bolus followed by 50-100 mg/m²/24 hours divided every 6 hours. 1
Adult Dosing by Clinical Scenario
Acute Adrenal Crisis
- Initial bolus: 100 mg IV hydrocortisone immediately
- Maintenance: 200 mg/24 hours via:
- Continuous IV infusion (preferred), OR
- 50 mg IV every 6 hours
- Reduce to 100 mg/day the following day as patient stabilizes 1
Septic Shock
- 200 mg/day in four divided doses (50 mg every 6 hours) OR as continuous infusion at 240 mg/day (10 mg/hr) for ≥7 days 2
- Alternative regimen: 100 mg every 12 hours appears equally effective with lower hyperglycemia rates 3, 4
- Do NOT use high-dose/short-duration protocols 5
Major Surgery/Trauma/ICU-Level Stress
- 100 mg IV bolus at procedure start
- 200 mg/24 hours continuous infusion while NPO or experiencing postoperative nausea/vomiting 6
Minor to Moderate Surgical Stress
- 25-75 mg/24 hours for 1-2 days 1
Pediatric Dosing
Acute Adrenal Crisis
Weight-based approach (simplified):
- <15 kg (0-2 years): 25 mg IV
- 15-25 kg (2-6 years): 50 mg IV
- >25 kg (>6 years): 100 mg IV
Body surface area approach (more precise):
- Initial bolus: 50-100 mg/m² IV
- Maintenance: 50-100 mg/m²/24 hours divided every 6 hours OR 2-3 mg/m²/hour continuous infusion 6
Unable to Tolerate Oral Medication
- Infants: 25 mg IM
- School-age children: 50 mg IM
- Adolescents: 100 mg IM 1
Critical Implementation Details
Administration technique: IV push over 30 seconds for 100 mg doses; up to 10 minutes for doses ≥500 mg 7
Duration of high-dose therapy: Continue only until hemodynamic stability achieved, typically 48-72 hours maximum. Beyond this timeframe, hypernatremia becomes problematic 7
Fluid resuscitation is mandatory: Adults require 1000 mL isotonic saline in first hour; children need 20 mL/kg boluses (can repeat up to 60 mL/kg total) 1
Fludrocortisone is NOT needed acutely when using high-dose hydrocortisone (mineralocorticoid activity is sufficient at these doses) 6
Common Pitfalls to Avoid
Under-dosing is more dangerous than over-dosing in acute crisis situations—err on the side of higher doses initially 1
Do NOT use dexamethasone as first-line (least preferred alternative; only if no other glucocorticoid available) 1
Do NOT stop abruptly—taper gradually once crisis resolves. Typical taper: reduce to 100 mg/day on day 2, then transition to oral regimen (30-50 mg/m²/day in children, standard replacement doses in adults) 6
Monitor glucose hourly in children—treat if <3.5 mmol/L with 2-5 mL/kg of 10% dextrose 6
Watch for hyperglycemia in adults—occurs in 64-87% of patients on 200 mg/day regimens; consider 100 mg/day dosing if this becomes problematic 3