Hydrocortisone Dosing for Septic Shock
For patients with septic shock requiring vasopressors despite adequate fluid resuscitation, administer intravenous hydrocortisone at 200 mg per day, given either as a continuous infusion (preferred) or as 50 mg IV every 6 hours. 1, 2, 3, 4
When to Initiate Hydrocortisone
Start hydrocortisone only when hemodynamic stability cannot be achieved with adequate fluid resuscitation and moderate-to-high dose vasopressor therapy (typically norepinephrine >0.1-0.2 mcg/kg/min). 1, 2, 4
Do not use hydrocortisone in patients with sepsis who do not have shock—this provides no benefit. 2, 3, 4
The ACTH stimulation test should not be used to decide which patients receive hydrocortisone; the decision is purely clinical based on vasopressor requirements. 1, 2, 3, 4
Dosing Regimen Details
The standard dose is 200 mg per day—do not exceed 400 mg per day, as higher doses provide no additional benefit and may increase harm. 2, 4
Continuous infusion is preferred over intermittent boluses (200 mg/24 hours as continuous infusion vs. 50 mg IV every 6 hours). 2, 3, 4
While one retrospective study suggested 300 mg per day (100 mg every 8 hours) may reduce shock recurrence, this conflicts with guideline recommendations and a prospective trial showing no mortality benefit at 300 mg. 5, 6 Stick with the guideline-recommended 200 mg per day. 1, 2, 4
Duration and Tapering
Continue full-dose hydrocortisone for at least 3 days before considering any dose reduction. 2, 4
Begin tapering when vasopressors are no longer required, not before. 2, 3, 4
Taper gradually over 6-14 days rather than stopping abruptly—abrupt cessation causes hemodynamic deterioration and rebound inflammation. 2, 3, 4
Do not use a fixed duration approach; taper based on clinical response and vasopressor requirements. 4
Monitoring During Treatment
Monitor serum sodium for hypernatremia, especially beyond 48-72 hours of treatment. 4
Monitor blood glucose for hyperglycemia throughout therapy. 2, 4
Assess for superinfection, as corticosteroids increase this risk. 3, 4
Check clinical response after 2-3 days to determine if therapy should continue. 4
Critical Pitfalls to Avoid
Avoid etomidate for intubation in patients who may require hydrocortisone—it suppresses the HPA axis and worsens outcomes. 3, 4, 5
Never stop hydrocortisone abruptly; this causes hemodynamic and immunologic rebound. 2, 3, 4
Shock relapse after hydrocortisone cessation is associated with persistent infection and prior etomidate use—address these factors. 5
Evidence Quality Context
The recommendation for 200 mg per day is based on weak evidence (Grade 2D), but represents consensus across the Surviving Sepsis Campaign, Society of Critical Care Medicine, and European Society of Intensive Care Medicine. 1, 2, 3, 4 While older studies from 1998 showed benefit with 300 mg per day, more recent prospective trials found no mortality difference between 200 mg and 300 mg regimens. 5, 7 The guidelines prioritize the lower dose to minimize adverse effects while maintaining efficacy for shock reversal. 1, 2