Stress Dose Steroids for Adrenal Insufficiency

Initial Dosing for Major Stress

• The American College of Anaesthesiologists recommends giving hydrocortisone 50-100 mg IV bolus at the onset of major stress, followed immediately by continuous infusion 1, 2, 3
• Continuous IV infusion of 200 mg hydrocortisone over 24 hours is recommended for maintaining cortisol levels in the physiologic stress range 1, 2
• Alternatively, if continuous infusion is unavailable, give hydrocortisone 50 mg IV/IM every 6 hours 1, 2

Context: Why This Dose?

• During major physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 4, 5
• Adrenal crisis can occur even when plasma cortisol levels appear normal or elevated (relative adrenal insufficiency), making empiric dosing critical 6, 5

Tapering After Stabilization

• Once hemodynamically stable and tolerating oral intake, switch to oral hydrocortisone at double the usual maintenance dose 1, 2, 6, 5
• Continue doubled oral dose for 48 hours after minor/moderate stress, or up to 1 week following major surgery 1, 2, 5
• Taper stress-dose IV steroids down to oral maintenance doses over 5-7 days 3, 4

Mild to Moderate Stress (Sick Days)

• For febrile illness, minor procedures, or intercurrent illness: double the regular oral maintenance dose 1, 2
• Standard maintenance is hydrocortisone 15-20 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg evening) 3, 4

Pediatric Dosing

• Give hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia 1, 2
• Following major surgery: hydrocortisone 2 mg/kg IV/IM every 4 hours, or continuous infusion 1, 2

Obstetric Patients

• At onset of active labor: hydrocortisone 100 mg IV bolus (when contractions every 5 minutes for 1 hour, or cervical dilation >4 cm) 1, 2
• Follow with continuous infusion of 200 mg/24 hours, OR hydrocortisone 50 mg IM every 6 hours 1, 2

Critical Pitfalls to Avoid

• Never delay treatment while awaiting diagnostic confirmation—treat suspected adrenal crisis immediately 5
• Always start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen), as these accelerate cortisol clearance and can precipitate adrenal crisis 3, 4

Patient Education Requirements

• All patients must have emergency hydrocortisone injection kit (100 mg) for self-administration 4, 5
• Provide medical alert bracelet/necklace and steroid emergency card 2, 4, 5

Steroid Equivalencies

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 6, 4
• Only hydrocortisone provides mineralocorticoid activity at physiologic doses 6

Stress Dose Steroids: Dosing and Administration

Clinical Context: When Stress Dosing is Required

• In patients with intraoperative hypotension unresponsive to fluids and vasopressors, a rescue dose of 100 mg hydrocortisone IV, followed by 50 mg IV every 6 hours, is recommended by the World Journal of Emergency Surgery 7
• Hydrocortisone is the drug of choice for stress and rescue dose coverage, as it provides mineralocorticoid activity at physiologic doses, according to the World Journal of Emergency Surgery 7
• Unexplained intraoperative or postoperative hypotension despite fluids and vasopressors warrants empiric hydrocortisone, as suggested by the World Journal of Emergency Surgery 7
• Dexamethasone may be used as an alternative agent, as it has no mineralocorticoid activity and likely provides the same protective effect in short courses, according to the World Journal of Emergency Surgery 7

Peri‑Procedural Stress‑Dose Steroid Management for Adults with Primary Adrenal Insufficiency

Glucocorticoid Stress‑Dose Protocol

• Give an IV bolus of 100 mg hydrocortisone at the start of the procedure, followed immediately by a continuous IV infusion of 200 mg over 24 h. This regimen provides more stable physiologic cortisol levels than intermittent bolus dosing. 8
• Renal artery embolization is classified as a major/intermediate stressor that requires full stress‑dose glucocorticoid coverage. 9
• If a continuous infusion cannot be administered, give 50 mg hydrocortisone IV or IM every 6 h. 8
• Maintain the 200 mg/24 h IV infusion while the patient is NPO or experiencing nausea/vomiting. 9
• When oral intake is tolerated and hemodynamics are stable, switch to oral hydrocortisone at twice the patient’s usual maintenance dose. 8
• Continue the doubled oral dose for at least 48 h after an uncomplicated procedure. 9
• If procedural complications occur, extend the doubled oral dose for up to 1 week. 8

Fluid and Electrolyte Management

• Patients with primary adrenal insufficiency lack both glucocorticoid and mineralocorticoid activity, making them prone to hyponatremia and volume depletion; aggressive isotonic fluid resuscitation is therefore essential. 10

Monitoring Requirements

• Measure blood pressure in both sitting and supine positions to detect orthostatic hypotension. 10
• Check serum sodium and potassium concentrations frequently. 10
• Watch for early signs of adrenal crisis—malaise, somnolence, cognitive dysfunction, or persistent hypotension despite fluids. 8

Critical Pitfalls to Avoid

• Do not use etomidate for sedation, as it rapidly suppresses cortisol synthesis by inhibiting 11‑β‑hydroxylase. 10
• If etomidate has been administered, maintain a high index of suspicion for adrenal decompensation. 8
• Volume‑resistant hypotension is a late indicator of adrenal crisis; treat emerging symptoms (e.g., early hypotension, fatigue) promptly. 10
• Fever should not automatically be attributed to infection; adrenal insufficiency itself can cause pyrexia, and steroid dosing should not be reduced while fever persists. 10

Rationale and Evidence Summary

• Pharmacokinetic data demonstrate that continuous IV hydrocortisone infusion is the only administration method that consistently keeps cortisol concentrations within the physiologic stress range; intermittent bolus dosing produces peaks and troughs that may leave patients vulnerable to crisis. 8
• Procedural stress, contrast exposure, and post‑procedure pain collectively increase cortisol requirements, reinforcing the need for full stress‑dose coverage during renal artery embolization. 10