What is the typical dosage of Hydrocortisone (cortisol) intravenous (IV)?

Hydrocortisone IV Dosing

Hydrocortisone IV is typically dosed at 100 mg as an initial bolus followed by 200 mg/24 hours as a continuous infusion for stress coverage during surgery or critical illness, or 50-100 mg every 6-8 hours for acute adrenal crisis. 1, 2

Context-Specific Dosing Regimens

Septic Shock

• Administer 200 mg/day as a continuous infusion when adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability 1
• Do not use hydrocortisone if hemodynamic stability is achieved with fluids and vasopressors alone 1
• Taper hydrocortisone when vasopressors are no longer required 1
• Continuous infusion is preferred over bolus dosing 1

Peri-operative/Surgical Stress Coverage

For patients with adrenal insufficiency or on chronic steroids (≥5 mg prednisolone equivalent for ≥4 weeks): 1

• Induction: Hydrocortisone 100 mg IV bolus at induction of anesthesia 1
• Maintenance: Immediately initiate continuous infusion of 200 mg/24 hours 1
• Alternative: Hydrocortisone 50 mg IV/IM every 6 hours 1
• Postoperative: Continue 200 mg/24 hours IV while nil by mouth, then transition to double oral maintenance dose for 48 hours (up to 1 week for major surgery) 1

Acute Adrenal Crisis/Life-Threatening Situations

• Initial dose: 100-500 mg IV bolus depending on severity 2
• Maintenance: Repeat doses every 2,4, or 6 hours based on clinical response 2
• Severe cases: Hydrocortisone 50-100 mg IV every 6-8 hours 1
• High-dose therapy should not continue beyond 48-72 hours due to risk of hypernatremia 2

Immune-Related Adverse Events (Adrenal Insufficiency from Checkpoint Inhibitors)

• Grade 3-4: Hydrocortisone 50-100 mg IV every 6-8 hours initially 1
• Taper to oral maintenance over 5-7 days 1
• Grade 2: Hydrocortisone 30-50 mg total daily dose (stress dosing) for 2 days, then taper to maintenance 1

Pediatric Dosing

• Surgical stress: 2 mg/kg IV at induction, followed by continuous infusion based on weight: 1
  • Up to 10 kg: 25 mg/24 hours
  • 11-20 kg: 50 mg/24 hours
  • Over 20 kg prepubertal: 100 mg/24 hours
  • Pubertal: 150 mg/24 hours
• General range: 0.56-8 mg/kg/day in 3-4 divided doses (20-240 mg/m²/day) 2

Administration Considerations

Route and Timing

• Preferred emergency route: IV injection over 30 seconds (100 mg) to 10 minutes (≥500 mg) 2
• IV infusion or IM injection are acceptable alternatives 2
• Do not dilute or mix with other solutions due to physical incompatibilities 2

Monitoring and Adjustment

• Dosing must be individualized based on disease severity and clinical response 2
• After favorable response, decrease dose in small decrements to find lowest effective maintenance dose 2
• Body weight is the most important predictor of hydrocortisone clearance; weight-adjusted dosing reduces interpatient variability 3

Critical Pitfalls to Avoid

• Do not use hydrocortisone for sepsis without shock 1
• Do not perform ACTH stimulation testing to decide on hydrocortisone use in septic shock 1
• Avoid abrupt discontinuation after long-term therapy; taper gradually 2
• Monitor for hypernatremia if high-dose therapy continues beyond 48-72 hours; consider switching to methylprednisolone 2
• Ensure stress-dose coverage for any patient on chronic steroids (≥5 mg prednisolone equivalent for ≥4 weeks) undergoing surgery 1