Hydrocortisone Dosing for Pediatric Patients with Septic Shock
The recommended dose of hydrocortisone for pediatric patients with septic shock is 1 mg/kg every 6 hours. 1
Indications for Hydrocortisone in Pediatric Septic Shock
- Hydrocortisone should be considered in children with catecholamine-resistant septic shock 1, 2
- It is particularly indicated when there is suspected or proven adrenal insufficiency 2
- Noradrenaline is recommended as the first-line vasoactive drug treatment in pediatric septic shock, with hydrocortisone considered when shock is not responsive to fluid and vasopressor therapy 1
Dosing Recommendations
- The standard recommended dose is 1 mg/kg every 6 hours (4 mg/kg/day) 1
- For severe cases with refractory shock, doses may need to be increased up to 50 mg/kg/day 3
- Initial treatment should begin with stress doses of hydrocortisone at approximately 5-6 mg/kg/day 3
- Treatment should be continued for at least 5 days, followed by a tapering dose to avoid rebound inflammation 1, 4
Administration and Monitoring
- Hydrocortisone can be administered as intermittent doses every 6 hours or as a continuous infusion 4
- Blood pressure and hemodynamic parameters should be monitored during therapy 3
- Serum glucose should be monitored as hydrocortisone can cause hyperglycemia 3, 4
- Serum electrolytes, particularly potassium and sodium, should be monitored during treatment 3, 4
Evidence for Efficacy
- Studies suggest that early administration of hydrocortisone (within 3 hours of shock) may reduce the time needed to discontinue vasopressors 5
- Low-dose hydrocortisone (5 mg/kg/day) has shown a trend toward earlier reversal of shock and lower inotrope requirements, although not statistically significant in some studies 6
- Approximately 25% of children with septic shock have absolute adrenal insufficiency, defined as basal cortisol <18 μg/dL 3
Common Pitfalls to Avoid
- Delaying treatment while waiting for cortisol test results in a critically ill child with suspected adrenal insufficiency can be harmful 3
- Using dexamethasone instead of hydrocortisone is not recommended due to hydrocortisone's superior mineralocorticoid activity 3
- Abrupt discontinuation of hydrocortisone therapy should be avoided; instead, gradually taper the dose 3, 4
- Using hydrocortisone based solely on severity of illness rather than adrenal function assessment may be associated with worse outcomes 7
Special Considerations
- Blood should be drawn for baseline cortisol level determination before starting hydrocortisone therapy when possible, but treatment should not be delayed in critically ill patients 3
- Death from absolute adrenal insufficiency and septic shock can occur within 8 hours of presentation, making timely administration crucial 3, 2
- Continue treatment until shock resolves, then taper the dose gradually to minimize potential long-term toxicities 3
In summary, hydrocortisone at 1 mg/kg every 6 hours is the standard recommended dose for pediatric patients with septic shock, particularly when shock is resistant to fluid resuscitation and vasopressors. Higher doses may be needed in severe cases, and treatment should continue for at least 5 days followed by a gradual taper.