What is the appropriate dose of hydrocortisone (cortisol) for an 11-year-old patient weighing 35.5kg?

Hydrocortisone Dosing for an 11-Year-Old Weighing 35.5kg

For perioperative stress dosing or acute adrenal crisis management in this 11-year-old child, administer hydrocortisone 71 mg (2 mg/kg) as an intravenous bolus at induction, followed by 71 mg every 4 hours (or 50 mg/24 hours continuous infusion based on weight range) for major surgery or critical illness. 1

Context-Specific Dosing Recommendations

For Perioperative/Surgical Stress

• Initial bolus: 71 mg IV hydrocortisone (2 mg/kg) at induction for both minor and major surgery under general anesthesia 1
• Postoperative dosing for major surgery: 71 mg IV/IM every 4 hours until enteral intake is established 1
• Alternative continuous infusion: 50 mg/24 hours for children weighing 11-20 kg range (though this child is slightly above, the next bracket would apply) 1
• For minor surgery: Double the normal maintenance dose orally after the procedure, then return to standard dosing 1

For Septic Shock with Adrenal Insufficiency

• Stress coverage range: 35.5-71 mg/day (1-2 mg/kg/day) for basic stress coverage 1
• Maximum shock dosing: Up to 1,775 mg/day (50 mg/kg/day) can be titrated for reversal of refractory septic shock, though this extreme dose is reserved for life-threatening situations 1
• Practical septic shock dosing: If the child has suspected absolute adrenal insufficiency and remains in shock despite vasopressors, hydrocortisone 200 mg/24 hours continuous infusion (adult equivalent, scaled appropriately) or intermittent dosing can be used 1

For Acute Severe Colitis (if applicable)

• Standard dosing: 100 mg IV every 6 hours (400 mg/day total) is the adult dose; pediatric equivalent would be approximately 71 mg every 6 hours based on weight-based scaling 1

Critical Dosing Principles

The dosing varies dramatically based on clinical context - from 1-2 mg/kg/day for maintenance stress coverage to 50 mg/kg/day for life-threatening shock 1:

• Maintenance/stress coverage: 35.5-71 mg/day divided doses 1
• Moderate stress (surgery): 71 mg bolus, then 71 mg every 4-6 hours 1
• Severe stress/septic shock: 200-1,775 mg/day depending on severity 1

Administration Considerations

Route Selection

• IV/IM preferred for acute situations, surgical stress, or inability to take oral medications 1
• Continuous infusion provides more stable cortisol levels during major stress compared to bolus dosing 2
• Oral dosing only appropriate for stable patients with functioning GI tract 1

Monitoring Requirements

• Blood glucose checks hourly if fasting exceeds 4 hours; no child with adrenal insufficiency should fast more than 6 hours 1
• Monitor for signs of fluid overload, electrolyte abnormalities, and hemodynamic stability 1
• For septic shock, target ScvO2 >70%, MAP appropriate for age, and capillary refill ≤2 seconds 1

Common Pitfalls to Avoid

• Do not delay hydrocortisone in suspected adrenal crisis while awaiting cortisol levels - treat first, test later 1
• Do not use inadequate dosing in true shock states - the 1-2 mg/kg/day maintenance dose is insufficient for hemodynamic instability requiring vasopressors 1
• Do not abruptly discontinue after high-dose therapy - taper over 1-3 days once stability achieved 1
• Do not use oral dosing in patients with nausea, vomiting, or hemodynamic instability 1

Tapering Protocol Post-Crisis

Once hemodynamic stability is achieved and vasopressors are no longer required:

• Reduce to double the normal maintenance dose for 48 hours 1
• Then taper to standard replacement doses over 1-3 days 1
• Resume normal maintenance dosing (typically 8-10 mg/m²/day divided 2-3 times daily) 1