What is the recommended regimen for stress dose steroids in ICU patients?

ICU Stress Dose Steroids: Recommended Regimen

For ICU patients with septic shock unresponsive to fluids and moderate-to-high dose vasopressors (>0.1 μg/kg/min norepinephrine equivalent), use IV hydrocortisone <400 mg/day for at least 3 days at full dose, administered either as continuous infusion (200 mg/24 hours) or as divided doses (50 mg IV every 6 hours). 1

When to Initiate Stress Dose Steroids

Septic Shock (Primary Indication):

• Start corticosteroids only when shock remains refractory despite adequate fluid resuscitation AND moderate-to-high dose vasopressors (>0.1 μg/kg/min norepinephrine or equivalent) 1
• Do NOT use corticosteroids in sepsis without shock—no mortality benefit and potential harm 1

Other ICU Conditions:

• Early moderate-to-severe ARDS (PaO2/FiO2 <200 within 14 days of onset): methylprednisolone 1 mg/kg/day 2
• Major trauma: corticosteroids NOT recommended 2

Specific Dosing Regimens

Standard Septic Shock Protocol:

• Hydrocortisone 200 mg/day as continuous IV infusion over 24 hours (preferred method) 1, 3
• Alternative: Hydrocortisone 50 mg IV bolus every 6 hours (if continuous infusion unavailable) 1, 3
• Duration: Minimum 3 days at full dose, continue until vasopressors no longer required 1

Refractory Shock (Rescue Dosing):

• For intraoperative/postoperative hypotension unresponsive to fluids and vasopressors: hydrocortisone 100 mg IV bolus, then 50 mg IV every 6 hours 3

ARDS-Specific Protocol:

• Methylprednisolone 1 mg/kg/day IV for ≥14 days in early moderate-to-severe ARDS 4, 2

Critical Dosing Principles

Why Low-Dose, Long-Duration:

• Cochrane meta-analysis of 4,268 patients demonstrated mortality benefit only with doses <400 mg/day hydrocortisone for ≥3 days at full dose 1
• High-dose, short-course regimens do NOT improve outcomes 1
• Survival benefits are dose-dependent: lower doses for longer duration are superior 1

Hydrocortisone vs Other Steroids:

• Hydrocortisone is preferred because it provides mineralocorticoid activity at physiologic doses 3
• Network meta-analysis showed no clear superiority of one corticosteroid over another, but hydrocortisone boluses/infusions were more effective than methylprednisolone for shock reversal 1
• Dexamethasone is NOT recommended for critical illness-related corticosteroid insufficiency 4

Tapering and Discontinuation

When to Taper:

• Begin taper when vasopressors are no longer required 1
• Do NOT stop abruptly after >few days of treatment 5, 6

Tapering Method:

• Taper stress-dose IV steroids down to oral maintenance doses over 5-7 days 5, 3
• Once hemodynamically stable and tolerating oral intake, switch to oral hydrocortisone at double the usual maintenance dose 3
• Continue doubled oral dose for 48 hours after minor/moderate stress, or up to 1 week following major surgery 3

Pitfall Alert:

• Recent data shows 50% of patients receive heterogeneous taper regimens with increased vasopressor requirements at 24 hours post-taper initiation (37.4% vs 21.3%, P=0.004) 7
• Consider reinstituting treatment if signs of sepsis, hypotension, or worsening oxygenation recur 4

Monitoring and Adverse Effects

Expected Adverse Effects:

• Hyperglycemia is the most common adverse event (90.9% vs 81.5% in placebo) 1
• Hypernatremia may occur 1
• NO increased risk of secondary infections (RR 1.02,95% CI 0.87-1.20) 1
• NO increased risk of gastrointestinal bleeding 1

What NOT to Monitor:

• Do NOT use ACTH stimulation test to identify which septic shock patients should receive hydrocortisone 1
• Random cortisol levels and delta cortisol may be used clinically but are not required to initiate treatment 2

Common Pitfalls to Avoid

Timing Errors:

• Never delay treatment in suspected adrenal crisis while awaiting diagnostic confirmation 3
• Do NOT start other hormone replacements (thyroid, testosterone, estrogen) before corticosteroids—these accelerate cortisol clearance and can precipitate adrenal crisis 5, 3

Dosing Errors:

• Avoid high-dose, short-course regimens (>400 mg/day for <3 days)—no benefit and potential harm 1
• Do NOT use low-dose dopamine for "renal protection" in conjunction with steroids 1

Patient Selection Errors:

• Do NOT use corticosteroids in sepsis without shock—the HYPRESS trial showed no benefit in preventing progression to shock and increased hyperglycemia (90.9% vs 81.5%) 1

Steroid Equivalencies

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 5, 3
• Only hydrocortisone provides mineralocorticoid activity at physiologic doses 3