Corticosteroid (ICU/Septic Shock)
Pregnancy: Use with caution — short-term use acceptable in septic shock; crosses placenta minimally
Hydrocortisone (ICU — Stress Dosing)
Brand names: Solu-Cortef
Adult dose
Dose: Septic shock: 200 mg/day IV (50 mg every 6h or 200 mg/24h infusion); Addisonian crisis: 100 mg IV bolus then 200 mg/24h
Route: IV
Frequency: Every 6 hours or continuous infusion
Max: 200 mg/day (septic shock protocol)
Used in refractory septic shock not responding to vasopressors. Continues for 5–7 days then taper. Add fludrocortisone 50 mcg once daily orally if available (APROCCHSS trial). Continuous infusion preferred to bolus dosing (avoids glucose spikes).
Paediatric dose
Dose: 1–2 mg/day/kg
Route: IV
Frequency: Divided every 6 hours
Max: 200 mg/day
Paediatric septic shock: 1–2 mg/kg/day in divided doses under specialist guidance.
Dose adjustments
Renal
No dose adjustment required.
Hepatic
No dose adjustment required.
Paediatric weight-based calculator
Paediatric septic shock: 1–2 mg/kg/day in divided doses under specialist guidance.
Clinical pearls
- APROCCHSS trial (2018): hydrocortisone + fludrocortisone in septic shock — significant mortality reduction (43% vs 49%); ADRENAL trial (2018): hydrocortisone alone — no mortality benefit but faster vasopressor weaning. Current practice: use in vasopressor-dependent refractory shock.
- Surviving Sepsis 2021: suggest IV hydrocortisone 200 mg/day if haemodynamic stability not achieved with fluids and vasopressors
- Strict glucose control required — target 6–10 mmol/L in ICU; hyperglycaemia worsens outcomes
Contraindications
- Systemic infection without adequate antimicrobial cover
Side effects
- Hyperglycaemia (requires insulin infusion)
- Hypokalaemia
- Fluid retention
- Immunosuppression
- GI bleeding (especially with NSAIDs)
- Delirium (high doses)
- Adrenal suppression on withdrawal
Interactions
- Amphotericin B (additive hypokalaemia)
- NSAIDs (increased GI bleeding)
- Rifampicin (reduces steroid effect)
- Antidiabetics (hyperglycaemia antagonism)
Monitoring
- Blood glucose (4-hourly minimum)
- Serum potassium
- Vasopressor requirements (weaning marker)
- Signs of secondary infection
Reference: BNFc; BNF 90; APROCCHSS Trial (NEJM 2018); ADRENAL Trial (NEJM 2018); Surviving Sepsis Campaign 2021. Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.
Calculators