Hydrocortisone Administration in Special Populations

Perioperative Considerations

The American Society of Anesthesiologists recommends administering hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg over 24 hours for major surgery in adults with adrenal insufficiency 1
For adults on chronic glucocorticoid therapy, the same protocol as adrenal insufficiency is recommended for major surgery—100 mg IV at induction, then 200 mg/24h continuous infusion 1
Alternative option for major surgery: dexamethasone 6-8 mg IV provides adequate coverage for 24 hours 1
Postoperatively, continue 200 mg/24h IV infusion while nil by mouth or if vomiting occurs 1
Once oral intake resumes, double the usual oral hydrocortisone dose for 48 hours after uncomplicated surgery, or up to one week following major surgery 1

The American Academy of Pediatrics recommends children with adrenal insufficiency require 2 mg/kg IV hydrocortisone at induction for any surgery under general anesthesia 2, 3
Postoperatively after major surgery: 2 mg/kg every 4 hours IV/IM, or continuous infusion if unstable 2, 3
No child with adrenal insufficiency should be fasted >6 hours 2, 3
Monitor blood glucose hourly if fasting exceeds 4 hours and until enteral intake resumes 2, 3

The American College of Obstetricians and Gynecologists recommends administering hydrocortisone 100 mg IV at onset of active labor, followed by continuous infusion of 200 mg/24h 4, 3
Alternative: hydrocortisone 50 mg IM every 6 hours 4, 3
Rapid taper over 1-3 days to regular replacement dose after uncomplicated delivery 4, 3
Consider increasing maintenance dose by 20-40% in late pregnancy, as physiologic cortisol increases during this period 3

The Society of Critical Care Medicine recommends using hydrocortisone 200 mg/day ONLY if adequate fluid resuscitation and vasopressors fail to restore hemodynamic stability in septic shock 5
Administer as continuous infusion rather than bolus dosing 5
Do NOT use ACTH stimulation test to determine who should receive hydrocortisone 5
Taper hydrocortisone when vasopressors are no longer required 5
Do NOT administer corticosteroids for sepsis without shock 5

The Endocrine Society recommends immediately administering hydrocortisone 100 mg IV bolus, followed by 100-300 mg/day as continuous infusion or 50 mg IV/IM every 6 hours for acute adrenal crisis 6
Simultaneously give rapid IV infusion of 0.9% saline (1 L over first hour) 6
Do NOT delay treatment for diagnostic testing—draw blood for cortisol/ACTH, then treat immediately 6
Continue IV saline at slower rate for 24-48 hours 6
Taper parenteral glucocorticoids over 1-3 days to oral replacement once stable 6
Restart fludrocortisone when hydrocortisone dose falls below 50 mg/day 6

Patients with concurrent diabetes insipidus and adrenal insufficiency require strict fluid balance monitoring, as cortisol is necessary to excrete water loads 2, 3
Mandatory strict fluid balance with adequate cortisol replacement to avoid hyponatremia and associated morbidity 2, 3