Hydrocortisone (Hydracort): Indications, Dosing, and Clinical Applications
Primary Indications
Hydrocortisone is indicated for adrenal insufficiency replacement therapy, perioperative stress-dose coverage in at-risk patients, acute adrenal crisis, and as adjunctive therapy in refractory septic shock when vasopressors fail to restore hemodynamic stability. 1, 2
Acute Adrenal Crisis
Immediate Management
- Administer hydrocortisone 100 mg IV bolus immediately without waiting for diagnostic confirmation 1, 2
- Draw blood for cortisol and ACTH before treatment, but do not delay therapy for results 1, 2
- Simultaneously infuse 0.9% saline 1 liter over the first hour 1, 2
Continuation Therapy
- Follow with 100-300 mg/day as continuous IV infusion, or alternatively 50 mg IV/IM every 6 hours 2
- Continue IV saline at slower rate for 24-48 hours 2
- Taper parenteral glucocorticoids over 1-3 days to oral replacement once stable 2
- Restart fludrocortisone when hydrocortisone dose falls below 50 mg/day 2
Perioperative Stress-Dose Coverage
Major Surgery (Adults with Adrenal Insufficiency)
Administer hydrocortisone 100 mg IV at induction, followed immediately by continuous infusion of 200 mg over 24 hours. 1, 2
Postoperative Management
- Continue 200 mg/24h IV infusion while nil by mouth or if vomiting 1, 2
- Alternative: hydrocortisone 50 mg IM every 6 hours 1
- Once oral intake resumes: double usual oral hydrocortisone dose for 48 hours after uncomplicated surgery 1, 2
- For major surgery with prolonged recovery: continue doubled oral dose for up to one week 1, 2
Minor Surgery and Procedures
- Administer hydrocortisone 100 mg IV/IM just before procedure 1
- Postoperatively: double oral dose for 24 hours, then return to normal 1
Dental Procedures
Invasive Bowel Procedures Requiring Laxatives
- Hospital admission with 100 mg hydrocortisone IM and IV fluids during bowel preparation 1
- Repeat 100 mg dose before procedure start 1
- Double oral dose for 24 hours after procedure 1
Obstetric Applications
Labor and Vaginal Delivery
- Administer hydrocortisone 100 mg IV at onset of active labor, followed by continuous infusion of 200 mg/24h 1, 2
- Alternative: hydrocortisone 50 mg IM every 6 hours 1, 2
- Postpartum: double oral dose for 24-48 hours after delivery 1, 2
- Rapid taper over 1-3 days to regular replacement dose after uncomplicated delivery 2
Caesarean Section
- Follow major surgery protocol: 100 mg IV at induction, then 200 mg/24h continuous infusion 1
- Double oral doses for 48 hours once oral intake resumes 1
Septic Shock Management
Use hydrocortisone 200 mg/day ONLY if adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability. 1, 2
Critical Protocol Details
- Administer as continuous infusion rather than bolus dosing 1, 2
- Do NOT use ACTH stimulation test to determine who should receive hydrocortisone 1, 2
- Taper hydrocortisone when vasopressors are no longer required 1, 2
- Do NOT administer corticosteroids for sepsis in the absence of shock 1, 2
Important Caveat
This represents a conditional recommendation based on weak evidence; hydrocortisone should not be routine in septic shock but reserved for refractory cases 1
Severe Community-Acquired Pneumonia
In ICU patients with severe community-acquired pneumonia, hydrocortisone 200 mg daily for 4-7 days (followed by tapering for total 8-14 days) reduces 28-day mortality from 11.9% to 6.2%. 3
- This represents the highest quality recent evidence for mortality benefit in a specific acute condition 3
- Treatment also reduced need for mechanical ventilation (18.0% vs 29.5%) and vasopressor initiation (15.3% vs 25.0%) 3
Chronic Oral Replacement Therapy
Standard Dosing
- Initial dosage ranges from 20-240 mg/day depending on disease severity 4
- For adrenal insufficiency replacement: typically 15-25 mg/day divided into 2-3 doses 1
- Highest dose should be given in early morning to mimic physiological cortisol rhythm 5
Dose Equivalency
- 20 mg hydrocortisone = 5 mg prednisone (4:1 conversion ratio) 6
- 200 mg hydrocortisone = 50 mg prednisone 6
Monitoring and Adjustment
- Dosage must be individualized based on clinical response 7, 4
- Increase doses during illness, fever, infection, or other physiological stress 1
- For mild illness: double usual dose for 24-48 hours 1
- Taper gradually rather than abruptly after long-term therapy 7, 4
Pediatric Considerations
Perioperative Management
- Children with adrenal insufficiency require 2 mg/kg IV hydrocortisone at induction for any surgery under general anesthesia 2
- Postoperatively after major surgery: 2 mg/kg every 4 hours IV/IM, or continuous infusion if unstable 2
Critical Safety Measures
- No child with adrenal insufficiency should be fasted >6 hours 2
- Monitor blood glucose hourly if fasting exceeds 4 hours and until enteral intake resumes 2
Special Population: Diabetes Insipidus with Adrenal Insufficiency
- Patients with concurrent diabetes insipidus and adrenal insufficiency require strict fluid balance monitoring 2
- Cortisol is necessary to excrete water loads; inadequate replacement risks severe hyponatremia 2
- Mandatory strict fluid balance with adequate cortisol replacement to avoid hyponatremia-associated morbidity 2
Administration Routes and Preparation
Intravenous Administration
- For emergency use: administer 100 mg over 30 seconds to 500 mg over 10 minutes 7
- For continuous infusion: add 100-3000 mg to 50-1000 mL of 5% dextrose or normal saline 7
- Solutions stable for at least 4 hours after reconstitution 7
Intramuscular Administration
- Reconstitute with ≤2 mL Bacteriostatic Water for Injection 7
- Suitable for emergency situations when IV access unavailable 7
Critical Pitfalls to Avoid
Never Delay Treatment
- In suspected adrenal crisis, draw blood samples but initiate treatment immediately without waiting for results 1, 2
- Even mild gastrointestinal upset can precipitate crisis as patients cannot absorb oral medication when needed most 1
Perioperative Errors
- Do not underestimate stress of "minor" procedures in patients with adrenal insufficiency 1
- Always provide stress-dose coverage for any procedure requiring anesthesia 1, 2
Septic Shock Misuse
- Do not use hydrocortisone routinely in septic shock—only when vasopressors fail 1, 2
- Do not use ACTH stimulation testing to guide therapy in septic shock 1, 2