What is the recommended stress dose of hydrocortisone (cortisol) in patients with sepsis?

Recommended Hydrocortisone Dosing in Sepsis

For patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy, intravenous hydrocortisone should be administered at a dose of 200 mg per day. 1

Indications for Hydrocortisone in Sepsis

• Hydrocortisone should not be routinely used in all patients with sepsis 1
• Hydrocortisone is indicated specifically for patients with septic shock who remain hemodynamically unstable despite:
  • Adequate fluid resuscitation
  • Vasopressor therapy 1
• The evidence does not support using hydrocortisone in patients with sepsis without shock 1, 2

Dosing Recommendations

• The recommended dose is intravenous hydrocortisone <400 mg/day for ≥3 days at full dose 1
• More specifically, 200 mg per day is the standard recommended dose for adults with septic shock 1
• Administration options:
  • Continuous infusion of 200 mg/day 2
  • Divided doses (e.g., 50 mg every 6 hours) 3, 4

Duration of Therapy

• Continue treatment for at least 3 days at full dose 1
• Treatment should be continued until shock resolves 3
• Some evidence suggests 7 days of treatment for confirmed adrenal insufficiency 5, 6
• After stabilization, gradually taper the dose to minimize potential adverse effects 3

Timing of Initiation

• Hydrocortisone should be started immediately after determining that the patient has septic shock unresponsive to fluids and vasopressors 1
• Early initiation (within 3 hours) may reduce the time needed to discontinue vasopressors compared to later initiation 7

Special Considerations

• Consider testing for adrenal insufficiency before starting treatment, though treatment should not be delayed while awaiting results 3
• Delta cortisol (change in baseline cortisol at 60 min of <9 μg/dl) after cosyntropin (250 μg) administration or a random plasma cortisol of <10 μg/dl may help identify patients with adrenal insufficiency 1
• Approximately 25% of children with septic shock have absolute adrenal insufficiency 8

Monitoring During Treatment

• Monitor blood pressure and hemodynamic parameters 8, 3
• Watch for hyperglycemia, which is a common side effect of hydrocortisone therapy 8, 6
• Monitor serum electrolytes, particularly potassium and sodium 8
• Be vigilant for signs of secondary infection, which may be masked by corticosteroid therapy 8, 2

Common Pitfalls to Avoid

• Delaying treatment while waiting for cortisol test results in critically ill patients 8, 3
• Using hydrocortisone in patients with sepsis without shock 1, 2
• Abrupt discontinuation of hydrocortisone therapy rather than gradual tapering 8, 3
• Failing to monitor for hyperglycemia during treatment 8, 2

Pediatric Considerations

• For children with septic shock, stress-dose corticosteroids may be considered when unresponsive to fluids and requiring vasoactive support 1
• In newborns, the initial hydrocortisone dose is approximately 5-6 mg/kg/day, which can be titrated up to 50 mg/kg/day if needed to reverse shock 8