Intravenous Hydrocortisone Dosing for Adrenal Insufficiency
For acute adrenal crisis or major physiological stress in adults with adrenal insufficiency, administer hydrocortisone 100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours. 1, 2, 3
Acute Adrenal Crisis Management
- Initial bolus: Hydrocortisone 100 mg IV or IM immediately upon recognition of adrenal crisis 2, 3
- Maintenance: Continuous IV infusion of 200 mg hydrocortisone over 24 hours 1, 3, 4
- Alternative to continuous infusion: Hydrocortisone 50 mg IV or IM every 6 hours (total 200 mg/24h) 1, 2
- Fluid resuscitation: Administer 0.9% saline 1000 mL within the first hour alongside hydrocortisone 3
The continuous infusion approach is superior to intermittent bolus dosing because it maintains cortisol concentrations consistently within the physiological stress range, whereas bolus administration creates peaks and troughs that may inadequately cover the stress response 4.
Context-Specific Dosing Protocols
Major Surgery or Severe Illness
- Induction/onset: Hydrocortisone 100 mg IV bolus 1, 2
- Continuous coverage: 200 mg/24h continuous IV infusion until patient can tolerate oral intake 1, 2
- Duration: Continue until patient is stable and oral intake resumes, typically 24-48 hours 1
Moderate Stress (Body Surface/Intermediate Surgery)
- Initial dose: Hydrocortisone 100 mg IV at induction 1
- Maintenance: 200 mg/24h continuous IV infusion 1
- Transition: Double regular oral glucocorticoid dose for 48 hours once stable 1
Labor and Vaginal Delivery
- Onset of labor: Hydrocortisone 100 mg IV 1, 2
- Continuous coverage: 200 mg/24h IV infusion throughout labor 1, 2
- Alternative: Hydrocortisone 100 mg IM followed by 50 mg IM every 6 hours 1, 2
Minor Procedures with General Anesthesia
- Single dose: Hydrocortisone 100 mg IV at induction 1
- Postoperative: Resume oral dosing at double maintenance dose for 24-48 hours 1
Pediatric Dosing
- Major surgery bolus: Hydrocortisone 2 mg/kg IV at induction 1, 2
- Continuous infusion (weight-based): 1
- Up to 10 kg: 25 mg/24h
- 11-20 kg: 50 mg/24h
- Over 20 kg (prepubertal): 100 mg/24h
- Over 20 kg (pubertal): 150 mg/24h
- Alternative: Hydrocortisone 2 mg/kg IV or IM every 4 hours 1
Children with adrenal insufficiency are more vulnerable to hypoglycemia than adults and require frequent blood glucose monitoring during stress dosing 2.
Critical Clinical Pitfalls
Avoid Dexamethasone Monotherapy
Dexamethasone lacks mineralocorticoid activity and is inadequate for treating primary adrenal insufficiency, where aldosterone deficiency is also present 2. While dexamethasone 6-8 mg IV may suffice for 24 hours in patients with secondary adrenal insufficiency or those on chronic steroids undergoing surgery 1, hydrocortisone remains the preferred agent for adrenal crisis.
When in Doubt, Treat
If uncertainty exists about whether a patient requires stress-dose glucocorticoids, administer them—there are no long-term adverse consequences of short-term high-dose hydrocortisone administration, but withholding treatment can be fatal 2.
Infection as Primary Trigger
Infections are the most common precipitating cause of adrenal crisis 3. During acute infection (such as COVID-19 with continuous high fever), patients should take oral stress doses of hydrocortisone 20 mg every 6 hours 5. If clinical deterioration occurs, immediately inject 100 mg hydrocortisone IM and transition to continuous IV infusion 5.
Tapering Strategy
- Uncomplicated recovery: Taper to double maintenance oral dose within 24-48 hours after stress resolution 1, 2
- Major/complicated surgery: Continue double oral dose for up to one week before returning to maintenance 1, 2
- Add fludrocortisone: Resume mineralocorticoid replacement (if applicable) once enteral feeding is established 1
The evidence strongly supports continuous IV infusion over intermittent bolus administration during major stress, as pharmacokinetic modeling demonstrates that only continuous infusion maintains cortisol concentrations persistently within the physiological stress range 4.