What is the recommended steroid stress dose?

Steroid Stress Dose Recommendations

For patients with adrenal insufficiency undergoing major stress (surgery, sepsis, trauma), administer hydrocortisone 100 mg IV bolus immediately, followed by continuous infusion of 200 mg over 24 hours. 1

Dosing by Clinical Scenario

Major Surgery or Critical Illness

• Give hydrocortisone 100 mg IV at induction/onset of stress, then immediately start continuous IV infusion of 200 mg/24 hours 1, 2
• Alternative if continuous infusion unavailable: hydrocortisone 50 mg IV/IM every 6 hours 1, 2
• This dosing achieves cortisol concentrations in the physiologic stress range (approximately 100 mg/day production during major stress, compared to normal 20 mg/day) 2, 3
• Continuous infusion is superior to bolus dosing for maintaining stable cortisol levels throughout the stress period 3

Postoperative Management

• Continue hydrocortisone 200 mg/24 hours IV infusion while NPO or with postoperative vomiting 1
• Once tolerating oral intake and hemodynamically stable: switch to oral hydrocortisone at double the usual maintenance dose 1, 2
• Continue doubled oral dose for 48 hours after minor/moderate surgery or up to 1 week following major surgery 1, 2

Unexplained Hypotension During Surgery

• If hypotension is unresponsive to fluids and vasopressors, give hydrocortisone 100 mg IV immediately, followed by 50 mg IV every 6 hours 1, 2
• This applies even when adrenal insufficiency is only suspected—never delay treatment for diagnostic confirmation 2, 4
• Adrenal crisis can occur despite normal or elevated cortisol levels (relative adrenal insufficiency) 2, 5, 4

Labor and Delivery

• At onset of active labor: hydrocortisone 100 mg IV bolus 1, 2
• Follow with continuous infusion 200 mg/24 hours OR hydrocortisone 50 mg IM every 6 hours 1, 2
• For cesarean section: use major surgery protocol 1

Pediatric Dosing

• Hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia 2
• Following major surgery: 2 mg/kg IV/IM every 4 hours or continuous infusion 2

Mild to Moderate Stress (Sick Days)

• For febrile illness or minor procedures: double the regular oral maintenance dose 2, 5
• Standard maintenance is hydrocortisone 15-20 mg daily in divided doses 2, 5

Alternative Agents

• Dexamethasone 6-8 mg IV can substitute for hydrocortisone and provides coverage for 24 hours 1
• However, hydrocortisone is preferred as it provides mineralocorticoid activity at physiologic doses 2

Critical Pitfalls to Avoid

Never Delay Treatment

• Treat suspected adrenal crisis immediately—do not wait for diagnostic confirmation 2, 4
• Mortality risk is significantly elevated in untreated adrenal insufficiency (risk ratio 2.19 for men, 2.86 for women) 4

Avoid Abrupt Discontinuation

• Taper stress-dose steroids over 5-7 days down to maintenance doses—never stop abruptly 5, 6
• Consider reinstituting treatment if signs of sepsis, hypotension, or worsening oxygenation recur 6

Hormone Replacement Sequence

• Always start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen) 2, 5
• Other hormones accelerate cortisol clearance and can precipitate adrenal crisis 2, 5

Patient Safety Requirements

• All patients must have emergency hydrocortisone injection kit (100 mg) for self-administration 2, 5, 4
• Provide medical alert bracelet/necklace and steroid emergency card 2, 4
• Educate on stress dosing for sick days 5

Evidence Quality Note

The 2020 UK guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology provide the most comprehensive and recent evidence-based recommendations 1. A 2020 pharmacokinetic study definitively demonstrated that continuous IV infusion maintains cortisol in the physiologic stress range better than intermittent bolus administration 3. However, the 2021 World Journal of Emergency Surgery guidelines note that evidence supporting routine stress dosing in patients on chronic steroids (without documented adrenal insufficiency) is insufficient 1.