Stress Dose Hydrocortisone Dosing
For major physiological stress (surgery, sepsis, trauma), administer hydrocortisone 50-100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours. 1, 2, 3
Initial Management for Major Stress
Give hydrocortisone 100 mg IV bolus at the onset of major stress (surgery, sepsis, severe trauma, active labor), administered over 30 seconds to 10 minutes 1, 2, 4
Immediately follow with continuous IV infusion of 200 mg hydrocortisone over 24 hours - this is the only delivery method that consistently maintains cortisol concentrations in the physiologic stress range 1, 2, 3
Alternative if continuous infusion unavailable: Hydrocortisone 50 mg IV/IM every 6 hours 1, 2
Rationale for This Dose
During major stress, cortisol requirements increase up to 5-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 2
Continuous infusion of 200 mg/24 hours preceded by 50-100 mg bolus was identified through pharmacokinetic modeling as optimal for maintaining cortisol in the required stress range 3
Critical pitfall: Adrenal crisis can occur even when plasma cortisol levels appear normal or elevated (relative adrenal insufficiency), making empiric dosing essential 1, 2
Tapering After Stabilization
Once hemodynamically stable and tolerating oral intake: Switch to oral hydrocortisone at double the usual maintenance dose 1, 2
Continue doubled oral dose for:
For prolonged critical illness: Continue stress-dose IV steroids, then taper down to oral maintenance doses over 5-7 days 1, 2
Standard maintenance is hydrocortisone 15-20 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg evening) 1, 2
Moderate Stress (Grade 2 Illness)
For moderate symptoms with ability to perform activities of daily living: Hydrocortisone 30-50 mg total daily dose (or prednisone 20 mg daily) 1
Decrease to maintenance doses after 2 days 1
Mild Stress (Sick Days, Minor Illness)
For febrile illness, gastroenteritis, or minor procedures: Double the regular oral maintenance dose 2
If usual dose is 10-5-5 mg hydrocortisone, increase to 20-10-10 mg 1
Specific Clinical Scenarios
Perioperative Management
Moderate surgery: Single dose of 100 mg hydrocortisone IV 1
Major surgery: 100 mg hydrocortisone IV before anesthesia, then every 8 hours for 4 doses total, then taper by half per day 1
The UK Anaesthesia guidelines recommend 100 mg IV at surgery start, then 200 mg/24h infusion, with doubled oral doses for 48h-1 week postoperatively depending on surgery magnitude 1
Obstetric Patients
At onset of active labor (contractions every 5 minutes for 1 hour, or cervical dilation >4 cm): Hydrocortisone 100 mg IV bolus 2
Follow with continuous infusion of 200 mg/24 hours, OR hydrocortisone 50 mg IM every 6 hours 2
Pediatric Dosing
Any surgery under general anesthesia: Hydrocortisone 2 mg/kg IV at induction 2
Following major surgery: Hydrocortisone 2 mg/kg IV/IM every 4 hours, or continuous infusion 2
Critical Pitfalls to Avoid
Never delay treatment while awaiting diagnostic confirmation - treat suspected adrenal crisis immediately with 100 mg IV hydrocortisone 2
Do not use doses exceeding 50 mg every 6 hours routinely - studies show 20 mg oral hydrocortisone produces supraphysiologic cortisol levels, and stress doses above 50 mg 6-hourly are rarely necessary 5
Always start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen), as these accelerate cortisol clearance and can precipitate adrenal crisis 2
Beware of medication errors on hospital wards - 8.6% of adrenal crisis cases are caused by insufficient glucocorticoid medication during inpatient stays, including omitted doses 1
Do not abruptly discontinue after prolonged high-dose therapy - taper gradually to avoid withdrawal 4
Patient Education Requirements
All patients must have emergency hydrocortisone injection kit (100 mg) for self-administration 2
Provide medical alert bracelet/necklace and steroid emergency card 1, 2
Educate on stress dosing for sick days and when to seek emergency care 1