ICU Stress Dose Steroids: Recommended Regimen

Introduction to Stress Dose Steroids

The American College of Critical Care Medicine recommends using IV hydrocortisone <400 mg/day for at least 3 days at full dose, administered either as continuous infusion (200 mg/24 hours) or as divided doses (50 mg IV every 6 hours) for ICU patients with septic shock unresponsive to fluids and moderate-to-high dose vasopressors (>0.1 μg/kg/min norepinephrine equivalent) 1, 2, 3

The Society of Critical Care Medicine suggests starting corticosteroids only when shock remains refractory despite adequate fluid resuscitation AND moderate-to-high dose vasopressors (>0.1 μg/kg/min norepinephrine or equivalent) 1, 2, 4
The American College of Critical Care Medicine advises against using corticosteroids in sepsis without shock—no mortality benefit and potential harm 1, 3, 4

The European Society of Intensive Care Medicine recommends hydrocortisone 200 mg/day as continuous IV infusion over 24 hours (preferred method) 1, 2, 5, 6
The American College of Critical Care Medicine suggests an alternative regimen of hydrocortisone 50 mg IV bolus every 6 hours (if continuous infusion unavailable) 1, 6
The Society of Critical Care Medicine recommends a minimum duration of 3 days at full dose, continuing until vasopressors are no longer required 1, 2, 3

A Cochrane meta-analysis of 4,268 patients demonstrated mortality benefit only with doses <400 mg/day hydrocortisone for ≥3 days at full dose 1, 2, 3
The American College of Critical Care Medicine states that high-dose, short-course regimens do NOT improve outcomes 1, 2
The European Society of Intensive Care Medicine found that survival benefits are dose-dependent: lower doses for longer duration are superior 1, 3, 4

The Society of Critical Care Medicine prefers hydrocortisone because it provides mineralocorticoid activity at physiologic doses 6
A network meta-analysis showed no clear superiority of one corticosteroid over another, but hydrocortisone boluses/infusions were more effective than methylprednisolone for shock reversal 1, 3, 4

The American College of Critical Care Medicine recommends beginning taper when vasopressors are no longer required 2, 5
The European Society of Intensive Care Medicine advises against stopping abruptly after >few days of treatment 7, 6

The Society of Critical Care Medicine expects hyperglycemia as the most common adverse event (90.9% vs 81.5% in placebo) 1, 3
The American College of Critical Care Medicine notes that hypernatremia may occur 1, 3
The European Society of Intensive Care Medicine found NO increased risk of secondary infections (RR 1.02, 95% CI 0.87-1.20) 1, 3
The American College of Critical Care Medicine states that there is NO increased risk of gastrointestinal bleeding 1, 3

The Society of Critical Care Medicine warns against delaying treatment in suspected adrenal crisis while awaiting diagnostic confirmation 6
The American College of Critical Care Medicine advises against starting other hormone replacements (thyroid, testosterone, estrogen) before corticosteroids—these accelerate cortisol clearance and can precipitate adrenal crisis 7, 6
The European Society of Intensive Care Medicine recommends avoiding high-dose, short-course regimens (>400 mg/day for <3 days)—no benefit and potential harm 1, 2
The American College of Critical Care Medicine suggests avoiding low-dose dopamine for "renal protection" in conjunction with steroids 5

The Society of Critical Care Medicine notes that hydrocortisone 20 mg = prednisone 5 mg = dexamethasone 0.75 mg 7, 6
The American College of Critical Care Medicine states that only hydrocortisone provides mineralocorticoid activity at physiologic doses 6