What is the recommended dosing of hydrocortisone (cortisol) for sepsis-induced hypotension?

Hydrocortisone Dosing in Septic Shock with Hypotension

For adults with septic shock that remains hypotensive despite adequate fluid resuscitation and moderate-to-high dose vasopressor therapy, administer intravenous hydrocortisone at 200 mg per day for at least 3 days at full dose. 1, 2

Indications for Hydrocortisone

• Only use hydrocortisone when hemodynamic stability cannot be achieved with adequate fluid resuscitation and vasopressor therapy 1, 3
• Do not use corticosteroids for sepsis in the absence of shock 1
• The threshold for "adequate vasopressor therapy" typically means moderate-to-high dose norepinephrine (generally >0.1-0.2 mcg/kg/min) 1, 2

Dosing Regimen

The standard dose is 200 mg per day of hydrocortisone, administered either as:

• Continuous infusion (preferred method) 1, 3
• Divided doses: 50 mg IV every 6 hours 4, 5

The continuous infusion is preferred over intermittent boluses based on guideline recommendations, though both are acceptable 1

Duration and Tapering

• Continue full-dose hydrocortisone for at least 3 days before considering any dose reduction 2, 3
• Begin tapering when vasopressors are no longer required, not before 1, 2
• Taper gradually over 6-14 days rather than stopping abruptly to avoid rebound inflammation and hemodynamic deterioration 2
• Do not use a fixed duration approach; instead, taper based on clinical response and vasopressor requirements 2

Pediatric Dosing

For children with septic shock at risk for adrenal insufficiency who remain in shock despite epinephrine or norepinephrine:

• Dosing range: 1-2 mg/kg/day for stress coverage, up to 50 mg/kg/day titrated to reversal of shock 1
• May be administered as intermittent or continuous infusion 1

Maternal/Pregnancy Considerations

For pregnant patients with septic shock:

• Use the same adult dosing: hydrocortisone 200 mg per day 1
• Typical regimen: 50 mg IV every 6 hours or continuous infusion 1

What NOT to Do: Common Pitfalls

• Do not use the ACTH stimulation test to identify patients who should receive hydrocortisone 1, 3
• Do not use hydrocortisone doses >400 mg per day—higher doses provide no additional benefit and may increase harm 2
• Avoid etomidate for intubation in patients who may require hydrocortisone, as it suppresses the HPA axis and worsens outcomes 2, 6
• Do not stop hydrocortisone abruptly—this causes hemodynamic and immunologic rebound 2
• Do not use hydrocortisone if hemodynamic stability is achieved with fluids and vasopressors alone 1, 3

Expected Clinical Response

When hydrocortisone is appropriately indicated, expect:

• Rapid decrease in vasopressor requirements within 2-24 hours 7, 8
• Improved mean arterial pressure within hours of initiation 7, 8, 9
• Enhanced catecholamine responsiveness and restoration of vascular tone 7, 9
• Improved lactate clearance indicating better tissue perfusion 8

Monitoring During Treatment

• Monitor serum sodium for hypernatremia, especially if treatment extends beyond 48-72 hours 2, 4
• Monitor blood glucose for hyperglycemia 2
• Assess for superinfection, though risk appears minimal at physiologic doses 3, 5
• Check clinical response after 2-3 days to determine if therapy should continue 2

Administration Details

• Initial bolus of 100-200 mg IV can be given over 30 seconds to 10 minutes for rapid effect 4
• For continuous infusion: reconstitute and add to 50-1000 mL of 5% dextrose in water or normal saline 4
• Solutions stable for at least 4 hours after reconstitution 4