What is the stress dose steroid medication and dose for hypotension?

Stress Dose Steroid for Hypotension

For unexplained, fluid-unresponsive hypotension, administer hydrocortisone 100 mg IV push immediately, followed by 50 mg IV every 6 hours. 1, 2, 3

When to Administer Stress Dose Steroids

Rescue dosing is indicated specifically for hypotension that remains unresponsive to fluid resuscitation and vasopressor support. 1, 2, 3 The key clinical scenario is unexplained hypotension during or immediately surrounding surgery where adrenal insufficiency enters the differential diagnosis. 1

Specific Dosing Protocol

• Initial bolus: Hydrocortisone 100 mg IV push at onset of refractory hypotension 1, 2, 3
• Maintenance: Hydrocortisone 50 mg IV every 6 hours following the initial bolus 1, 2, 3
• Alternative continuous infusion: 200 mg hydrocortisone IV over 24 hours if continuous infusion is available 2

Context: Patients on Chronic Steroids

Patients on chronic steroid therapy (≥20 mg/day prednisone equivalent for ≥3 weeks) should continue their usual steroid dose perioperatively via IV route when oral intake is not possible. 1, 3 Current evidence does NOT support routine prophylactic "stress dosing" (200-300 mg hydrocortisone) for all patients on chronic steroids undergoing surgery. 1, 3

Conversion for Maintenance Dosing

• Prednisolone 5 mg = Hydrocortisone 20 mg = Methylprednisolone 4 mg 2, 3
• Simply convert the patient's usual oral dose to IV equivalent and continue scheduled administration 3

Pediatric Dosing for Hypotension

For children with septic shock and refractory hypotension unresponsive to fluids and vasopressors, stress-dose corticosteroids may be considered, though evidence is insufficient for routine use. 1

Pediatric Stress Dosing

• Preterm infants with refractory hypotension: Hydrocortisone 1 mg/kg IV every 8 hours for 5 days 4, 5
• Surgical stress in children: Hydrocortisone 2 mg/kg IV at induction, followed by 2 mg/kg IV/IM every 4 hours for major surgery 2

Evidence Quality and Nuances

The recommendation for 100 mg hydrocortisone bolus followed by 50 mg every 6 hours comes from moderate-quality guideline evidence specifically addressing perioperative hypotension. 1 This represents a consensus approach when adrenal crisis is suspected clinically, even though high-quality randomized data is limited. 1

Important distinction: The World Journal of Emergency Surgery guidelines explicitly state that routine prophylactic stress dosing (200-300 mg hydrocortisone) lacks supporting evidence and is not recommended. 1, 3 Reserve the 100 mg rescue dose specifically for unexplained hypotension that fails to respond to standard resuscitation. 1, 2, 3

Pediatric Septic Shock Evidence

In pediatric septic shock, the evidence is mixed and insufficient to support routine use. 1 Some studies show earlier shock reversal with low-dose hydrocortisone, while others show no survival benefit or even potential harm. 1 However, stress-dose steroids may be considered in children with fluid-refractory septic shock requiring vasoactive support. 1

Critical Pitfalls to Avoid

• Do not delay treatment while awaiting cortisol levels or ACTH stimulation testing—treat suspected adrenal crisis immediately based on clinical presentation 2
• Do not routinely give high-dose stress steroids (200-300 mg) to all patients on chronic steroids; this practice lacks evidence and may increase complications 1, 3
• Recognize increased surgical risk: Patients on chronic steroids have significantly higher rates of anastomotic leak (up to 6.2% vs 3.3%), wound dehiscence, and mortality 1
• HPA axis testing does not predict perioperative hypotension and should not guide treatment decisions 1

Clinical Algorithm

1. Identify refractory hypotension: Hypotension persisting despite adequate fluid resuscitation (typically 20-30 mL/kg) and vasopressor support (dopamine ≥10-14 mcg/kg/min or equivalent) 4, 5, 6

2. Administer rescue dose immediately: Hydrocortisone 100 mg IV push without delay 1, 2, 3

3. Continue maintenance: Hydrocortisone 50 mg IV every 6 hours 1, 2, 3

4. Taper after stabilization: Once hemodynamically stable and tolerating oral intake, switch to oral hydrocortisone at double the usual maintenance dose for 48 hours to 1 week depending on stress severity 2