When should intravenous (IV) hydrocortisone be used?

Indications for Intravenous Hydrocortisone Administration

IV hydrocortisone should primarily be used in septic shock unresponsive to fluid resuscitation and vasopressors, adrenal insufficiency during surgery or acute illness, and acute severe asthma exacerbations requiring hospitalization. The appropriate use of IV hydrocortisone is guided by specific clinical scenarios where rapid glucocorticoid action is required.

Septic Shock

• IV hydrocortisone at 200 mg/day (continuous infusion or divided doses) is indicated when:
  • Septic shock is not responsive to adequate fluid resuscitation and vasopressor therapy 1
  • Should be tapered when vasopressors are no longer required 1
  • Should NOT be used for sepsis without shock 1

Adrenal Insufficiency in Perioperative Settings

• For patients with known adrenal insufficiency undergoing surgery:

  • Major surgery: 100 mg IV at induction followed by continuous infusion of 200 mg/24h 1
  • Postoperatively: Continue 200 mg/24h IV infusion while nil by mouth (alternatively, 50 mg every 6h IM) 1
  • Resume enteral therapy at double the usual dose for 48h after major surgery 1

• For patients on chronic steroid therapy (prednisolone ≥5 mg for ≥4 weeks):

  • Follow similar protocol as for primary adrenal insufficiency 1
  • Hydrocortisone 100 mg IV at induction, then continuous infusion of 200 mg/24h 1

Critical Illness-Related Corticosteroid Insufficiency (CIRCI)

• IV hydrocortisone <400 mg/day for ≥3 days at full dose is suggested for:
  • Patients with septic shock unresponsive to fluid and moderate-to-high-dose vasopressor therapy 1
  • Random plasma cortisol <10 μg/dl may help identify candidates 1

Acute Severe Asthma

• IV hydrocortisone can be used for acute severe asthma exacerbations requiring hospitalization
• Evidence shows similar efficacy compared to methylprednisolone and dexamethasone 2
• Initial dose of 100-500 mg IV, depending on severity 3

Administration Considerations

• Can be administered by IV injection, IV infusion, or IM injection
• For emergency use, IV injection is preferred 3
• When given as continuous infusion, hydrocortisone 200 mg/24h is recommended 1
• High-dose therapy should generally not continue beyond 48-72 hours 3

Important Caveats and Pitfalls

1. Adrenocorticotropic hormone (ACTH) stimulation testing is NOT recommended to identify patients who should receive hydrocortisone in septic shock 1

2. Hypernatremia risk: When high-dose hydrocortisone therapy continues beyond 48-72 hours, consider switching to methylprednisolone which causes less sodium retention 3

3. Tapering: After favorable response, determine maintenance dosage by decreasing initial dose in small decrements at appropriate intervals 3

4. Discontinuation: After long-term therapy, withdraw gradually rather than abruptly 3

5. Monitoring: No established biomarker exists for cortisol activity, so clinical response remains the primary monitoring parameter 4

By following these evidence-based guidelines for IV hydrocortisone administration, clinicians can optimize patient outcomes while minimizing potential adverse effects associated with inappropriate glucocorticoid use.