Injectable Hydrocortisone in Pediatrics: Indications and Weight-Based Dosing
Primary Indications and Dosing
For children with fluid-refractory, catecholamine-resistant septic shock and suspected or proven absolute adrenal insufficiency, administer hydrocortisone at 2 mg/kg IV bolus initially, followed by continuous infusion or intermittent dosing ranging from 1-2 mg/kg/day for stress coverage up to 50 mg/kg/day titrated to reversal of shock. 1, 2
Septic Shock with Suspected Adrenal Insufficiency
Stress-dose corticosteroids may be considered in children with septic shock unresponsive to fluids and requiring vasoactive support, though there is insufficient evidence to support routine use in all children with septic shock 1
Approximately 25% of children with septic shock have absolute adrenal insufficiency (basal cortisol <18 μg/dL and peak ACTH-stimulated cortisol <18 μg/dL) 2, 3
Administer hydrocortisone ideally after obtaining a blood sample for baseline cortisol determination, but do not delay treatment in critically ill children 1, 2
Dosing range: 1-2 mg/kg/day for stress coverage to 50 mg/kg/day titrated to reversal of shock 1, 2
One pediatric RCT found no survival benefit with low-dose hydrocortisone, though another demonstrated earlier shock reversal 1, 2
Perioperative Stress Dosing for Known Adrenal Insufficiency
For major surgery under general anesthesia, administer hydrocortisone 2 mg/kg IV bolus at induction, followed by continuous IV infusion based on weight: 2
- Up to 10 kg: 25 mg/24 hours
- 11-20 kg: 50 mg/24 hours
- Over 20 kg prepubertal: 100 mg/24 hours
- Over 20 kg pubertal: 150 mg/24 hours
Postoperatively, give hydrocortisone 2 mg/kg IV or IM every 4 hours until stable and able to take oral medications 2, 4
For minor procedures not requiring general anesthesia, double the morning dose of hydrocortisone pre-operatively, then resume normal dosing 2
Newborns with Birth Asphyxia and Potential Adrenal Insufficiency
For newborns with birth asphyxia and catecholamine-resistant shock, start with hydrocortisone 50 mg/m²/24 hours (approximately 5-6 mg/kg/day), which can be titrated up to 50 mg/kg/day if needed to reverse shock 5
For a 3 kg newborn, this translates to an initial dose of 15-18 mg/day divided into 3-4 doses 5
Maximum dose in severe refractory shock can be up to 150 mg/day 5
Death from absolute adrenal insufficiency and septic shock can occur within 8 hours of presentation, making timely administration crucial 5
Administration Methods
Hydrocortisone can be administered as intermittent boluses every 6-8 hours or as a continuous infusion 1, 2
Intermittent dosing: 2 mg/kg IV or IM every 4-6 hours for acute stress 2, 4
Continuous infusion: Weight-based dosing as outlined above for perioperative management 2
Critical Monitoring Parameters
Monitor blood pressure and hemodynamic parameters every 5-15 minutes in children on vasopressors 2, 4
Check serum glucose hourly in children with adrenal insufficiency during perioperative fasting or acute illness, as hypoglycemia can develop rapidly 2, 4
No child with adrenal insufficiency should be fasted for more than 6 hours without IV dextrose 4, 5
Hypoglycemia and hypocalcemia should be corrected promptly 1, 2
Monitor serum electrolytes, particularly sodium and potassium 2, 5
Critical Pitfalls to Avoid
Avoid etomidate for intubation in children with septic shock or suspected adrenal insufficiency, as it suppresses the HPA axis and increases the risk of adrenal insufficiency 1, 2
Do not delay stress dosing while trying to determine if the child "really needs it"—err on the side of treatment in critically ill children with suspected adrenal insufficiency 4, 5
Never abruptly stop stress dosing—this can precipitate adrenal crisis; taper gradually once shock resolves 2, 4, 5
Do not use dexamethasone as the sole glucocorticoid in children with congenital adrenal hyperplasia, as it lacks mineralocorticoid activity and doesn't provide adequate replacement 4
Special Considerations for Congenital Adrenal Hyperplasia
For children with CAH who develop acute illness and cannot take oral medications, switch immediately to intravenous or intramuscular hydrocortisone at 2 mg/kg every 4-6 hours 4
Do not forget mineralocorticoid replacement (fludrocortisone) should be continued at the usual maintenance dose unless the child is receiving very high-dose hydrocortisone (>100 mg/day), which has intrinsic mineralocorticoid activity 4
Duration and Weaning
Continue treatment until shock resolves, then taper gradually to minimize potential long-term toxicities 2, 5
Pediatric patients may experience decreased growth velocity even at low systemic doses, so titrate to the lowest effective dose once stabilized 2