What is the recommended dosage and administration of stress doses of steroids, such as hydrocortisone (corticosteroid), for patients requiring them?

Stress Dose Steroids for Adrenal Insufficiency

For patients with adrenal insufficiency requiring stress dose steroids, administer hydrocortisone 100 mg IV immediately followed by 200-300 mg/day as continuous infusion or divided doses every 6 hours during major stress or surgery. 1

Dosing Recommendations Based on Stress Level

Adrenal Crisis/Major Stress (Surgery, Trauma, Critical Illness)

• Initial dose: Hydrocortisone 100 mg IV bolus immediately 2, 1
• Maintenance:
  • Continuous IV infusion: 200-300 mg/day (preferred method) 1, 3
  • OR divided doses: 50-100 mg IV every 6-8 hours 2, 1
• Fluid resuscitation: Rapid IV 0.9% saline (1L over first hour) 1
• Duration: Continue until hemodynamic stability is achieved 1

Post-Surgery Tapering

• Major surgery: Double regular oral replacement dose for 48 hours up to 1 week 2, 1
  • Example: If usual dose is 10-5-5 mg, increase to 20-10-10 mg 2
• Minor surgery: Double oral doses for 24 hours, then return to normal dose 1
• Complicated recovery: Continue IV stress dosing until condition stabilizes 2

Moderate Stress (Illness, Minor Procedures)

• Hydrocortisone 50-75 mg/day in divided doses 1
• OR 2-3 times maintenance dose (oral route if possible) 2, 1

Minor Stress/Illness

• Double or triple usual daily dose 1

Administration Methods

Continuous IV infusion is superior to intermittent bolus administration during major stress, as it maintains more consistent cortisol levels within the physiologic stress range 3. This approach better mimics the natural cortisol response to stress and prevents dangerous fluctuations in cortisol levels.

Special Considerations

1. Mineralocorticoid replacement:

   • Not needed with hydrocortisone at stress doses (has inherent mineralocorticoid activity)
   • Required if using dexamethasone as alternative 1

2. Monitoring during stress dosing:

   • Vital signs, especially blood pressure
   • Serum electrolytes (particularly sodium and potassium)
   • Clinical response (improvement in hypotension, mental status) 1

3. Adrenal crisis prevention:

   • Never abruptly discontinue steroids
   • All patients need education on stress dosing protocols 1
   • Medical alert identification is essential 2, 1

4. Septic shock:

   • Hydrocortisone 200 mg/day in four divided doses or as continuous infusion of 240 mg/day for ≥7 days 2, 4
   • Taper rather than abrupt discontinuation 2

Common Pitfalls

1. Inadequate initial dosing: Failure to give the 100 mg IV bolus before starting maintenance therapy can delay achieving therapeutic levels 1, 3

2. Inappropriate route: Oral administration during adrenal crisis is unreliable due to potential gastrointestinal absorption issues 1

3. Abrupt discontinuation: Always taper stress doses to maintenance levels to prevent rebound adrenal insufficiency 1

4. Failure to recognize adrenal insufficiency: Consider in any patient with unexplained hypotension, especially if unresponsive to fluids and vasopressors 2

5. Overreliance on testing: During acute stress, do not wait for confirmatory testing before initiating treatment if adrenal insufficiency is suspected 2, 1

The evidence strongly supports that continuous IV hydrocortisone infusion provides the most physiologic cortisol levels during major stress 3. This approach has been shown to reduce complications in trauma patients 5 and maintain more stable cortisol levels compared to intermittent dosing 6.