What is the recommended duration of treatment with hydrocortisone (cortisol) 100 mg?

Duration of Hydrocortisone 100 mg Treatment

The duration of hydrocortisone 100 mg treatment depends entirely on the clinical scenario: for major surgery, continue 100 mg every 6 hours for 24-48 hours postoperatively, then transition to double oral doses for 48 hours; for acute adrenal crisis, give 100 mg IV bolus followed by continuous infusion of 200 mg/24 hours until stable; for minor procedures, a single 100 mg dose is sufficient. 1

Perioperative Management

Major Surgery with Rapid Recovery

• Administer hydrocortisone 100 mg IV/IM at induction of anesthesia 1
• Continue 100 mg every 6 hours for 24-48 hours postoperatively 1
• Once able to eat and drink, transition to double the usual oral dose for 48 hours, then taper to normal maintenance dose 1

Major Surgery with Prolonged Recovery

• Give hydrocortisone 100 mg IV/IM at induction 1
• Continue 100 mg every 6 hours until patient can eat and drink 1
• After resuming oral intake, double the oral dose for 48+ hours before tapering to normal dose 1
• Alternatively, use continuous IV infusion of 200 mg/24 hours while nil by mouth 1, 2

Minor Surgery and Dental Procedures

• Single dose of 100 mg IV/IM just before anesthesia is sufficient 1
• Postoperatively, double the oral dose for 24 hours only, then return to normal maintenance 1

Acute Adrenal Crisis Management

Emergency Treatment

• Immediately administer hydrocortisone 100 mg IV bolus 2, 3
• Follow with continuous IV infusion of 200 mg/24 hours 2, 3
• Continue IV hydrocortisone while patient remains nil by mouth 2, 3
• Transition to oral glucocorticoids at double the usual maintenance dose for 48 hours once enteral route is available 2, 3

Labor and Delivery

Vaginal Delivery

• Give hydrocortisone 100 mg IV/IM at onset of labor 1
• Follow with either continuous infusion of 200 mg/24 hours OR 100 mg IM followed by 50 mg every 6 hours 1, 4
• Postpartum, double oral dose for 24-48 hours after delivery, then taper to normal dose 1

Cesarean Section

• Treat as major surgery with the same protocol outlined above 1

Special Considerations and Pitfalls

Alternative Dosing Regimens

• Dexamethasone 6-8 mg IV may substitute for hydrocortisone in major surgery and provides 24-hour coverage 1, 2, 4
• However, dexamethasone lacks mineralocorticoid activity and is inadequate as sole coverage for primary adrenal insufficiency 4

Monitoring During Treatment

• The 2020 Association of Anaesthetists guidelines emphasize that patients on chronic steroids (prednisolone equivalent ≥5 mg for 4 weeks or longer) require the same stress-dose coverage protocol 1, 2
• For primary adrenal insufficiency, add fludrocortisone once enteral feeding is established 2, 3

Common Pitfalls to Avoid

• Do not delay treatment for diagnostic procedures in suspected adrenal crisis - draw blood for cortisol and ACTH, then immediately start treatment 1
• Do not use fixed dosing without considering body weight - weight-adjusted dosing reduces interpatient variability in cortisol exposure 5
• Do not abruptly discontinue high-dose hydrocortisone - always taper through doubled oral doses before returning to maintenance 1

Pediatric Dosing Duration

• Children receive hydrocortisone 2 mg/kg IV/IM at induction, followed by weight-based continuous infusion 1, 2
• Once stable, double usual oral doses for 48 hours, then reduce to normal doses over up to one week 1, 2