What is the recommended dose of hydrocortisone (corticosteroid) to treat hypotension?

Hydrocortisone Dosing for Hypotension

For acute hypotension or adrenal crisis, administer hydrocortisone 100 mg IV bolus immediately, followed by 200 mg/24 hours as continuous infusion or 50 mg IV every 6 hours. 1

Clinical Context Determines Dosing

Adrenal Crisis or Suspected Adrenal Insufficiency

• Give 100 mg IV hydrocortisone immediately without waiting for diagnostic confirmation if the patient is unstable with volume-resistant hypotension 2, 1
• Follow with maintenance dosing of 200 mg/24 hours as continuous infusion or 50 mg IV every 6 hours 2, 1
• Continue full-dose therapy for at least 3-5 days before considering a taper 3, 4
• Never delay treatment for diagnostic procedures in suspected adrenal crisis—mortality is high if untreated 2, 1, 5

Septic Shock (Vasopressor-Dependent)

• Use hydrocortisone 200 mg/day (preferably as continuous infusion) only in patients who fail to achieve hemodynamic stability after adequate fluid resuscitation and moderate-to-high dose vasopressor therapy 1, 3, 4
• Administer for at least 3 days at full dose before initiating taper 3, 4
• Do not use corticosteroids for sepsis without shock—no benefit has been demonstrated 3
• Taper gradually over 6-14 days when vasopressors are discontinued rather than stopping abruptly to avoid rebound inflammation 3, 4

Perioperative Hypotension in Patients with Known Adrenal Insufficiency

• Hydrocortisone 100 mg IV at induction, followed immediately by continuous infusion of 200 mg/24 hours 2, 3
• Continue IV infusion while nil by mouth or if postoperative vomiting occurs 2
• Alternative: hydrocortisone 50 mg IM every 6 hours 2
• Resume oral dosing at double the usual replacement dose for 48 hours after uncomplicated surgery, or up to one week following major surgery 2

Perioperative Hypotension in Patients on Chronic Steroids

• For unexplained hypotension during surgery unresponsive to fluids, administer 100 mg hydrocortisone IV immediately and consider adrenal insufficiency 1
• Any patient taking ≥20 mg/day prednisone or equivalent for at least 3 weeks who develops unexplained hypotension should be presumed to have adrenal insufficiency until proven otherwise 5

Critical Dosing Principles

Initial Bolus Dose

• The standard initial dose is 100 mg IV hydrocortisone for acute situations 2, 1, 6
• In overwhelming, acute, life-threatening situations, doses exceeding usual dosages may be justified and may be in multiples of oral dosages 6
• The dose may be repeated at intervals of 2,4, or 6 hours as indicated by patient response 6

Maintenance Dosing Options

• Continuous infusion: 200 mg/24 hours (preferred for septic shock and critical illness) 2, 1, 3, 4
• Divided doses: 50 mg IV every 6 hours (alternative to continuous infusion) 2, 1
• Total daily dose range: 100-300 mg/day depending on severity 1

Administration Guidelines

• Administer IV bolus over 30 seconds (for 100 mg) to 10 minutes (for 500 mg or more) 6
• High-dose therapy should be continued only until patient stabilization, usually not beyond 48-72 hours 6
• When high-dose hydrocortisone therapy continues beyond 48-72 hours, hypernatremia may occur 6

Common Pitfalls to Avoid

Diagnostic Delays

• Never wait for cortisol levels or ACTH stimulation test results before treating suspected adrenal crisis 2, 1, 5
• The ACTH stimulation test should not be used to identify which septic shock patients should receive hydrocortisone 3, 4

Inappropriate Use

• Do not use corticosteroids for sepsis without shock—provides no benefit 3
• Avoid using corticosteroids in adults with influenza, as studies show increased risk of death (OR 3.06) and superinfection 3
• Do not use dexamethasone for critical illness-related corticosteroid insufficiency—it lacks mineralocorticoid activity and is inadequate for primary adrenal insufficiency 5, 4

Abrupt Discontinuation

• Never stop hydrocortisone abruptly—taper gradually over 6-14 days to avoid hemodynamic deterioration and rebound inflammation 3, 4
• Begin taper when vasopressors are no longer required, not based on arbitrary time frames 3, 4

Monitoring Failures

• Monitor for hypernatremia when therapy extends beyond 48-72 hours 6
• Monitor blood glucose levels during treatment, as hyperglycemia is common 3
• Watch for signs of infection, as corticosteroids blunt the febrile response 3

Special Populations

Neonates and Pediatric Patients

• Initial dose range: 0.56 to 8 mg/kg/day in three or four divided doses (20 to 240 mg/m²/day) 6
• A study in infants with refractory hypotension used 2.5 mg/kg every 12 hours for 48 hours, which reduced inotropic support requirements (60% vs 24%, P=0.009) 7

Patients with Concurrent Hypothyroidism

• Start corticosteroids several days before initiating thyroid hormone replacement to prevent precipitating adrenal crisis 5