Hydrocortisone Dosing in Septic Shock with Hypotension

Indications for Hydrocortisone

The American College of Critical Care Medicine recommends using hydrocortisone only when hemodynamic stability cannot be achieved with adequate fluid resuscitation and vasopressor therapy, with a typical threshold for "adequate vasopressor therapy" being moderate-to-high dose norepinephrine (generally >0.1-0.2 mcg/kg/min) 1, 2, 4
The Society of Critical Care Medicine suggests that corticosteroids should not be used for sepsis in the absence of shock 1, 2, 5

The standard dose is 200 mg per day of hydrocortisone, administered either as a continuous infusion (preferred method) or divided doses, with the continuous infusion being preferred over intermittent boluses based on guideline recommendations from the European Society of Intensive Care Medicine 1, 2, 5, 4

The Surviving Sepsis Campaign recommends continuing full-dose hydrocortisone for at least 3 days before considering any dose reduction, and beginning tapering when vasopressors are no longer required, not before 1, 2, 5, 3
The American College of Critical Care Medicine suggests tapering gradually over 6-14 days rather than stopping abruptly to avoid rebound inflammation and hemodynamic deterioration, and not using a fixed duration approach; instead, taper based on clinical response and vasopressor requirements 3

The Pediatric Critical Care Medicine society recommends a dosing range of 1-2 mg/kg/day for stress coverage, up to 50 mg/kg/day titrated to reversal of shock, which may be administered as intermittent or continuous infusion 7

The American College of Obstetricians and Gynecologists recommends using the same adult dosing: hydrocortisone 200 mg per day, with a typical regimen being 50 mg IV every 6 hours or continuous infusion 6

The Society of Critical Care Medicine advises against using the ACTH stimulation test to identify patients who should receive hydrocortisone, and against using hydrocortisone doses >400 mg per day, as higher doses provide no additional benefit and may increase harm 1, 2, 5, 4, 3
The American College of Critical Care Medicine recommends avoiding etomidate for intubation in patients who may require hydrocortisone, as it suppresses the HPA axis and worsens outcomes, and not stopping hydrocortisone abruptly, as this causes hemodynamic and immunologic rebound 3

The Surviving Sepsis Campaign suggests monitoring serum sodium for hypernatremia, especially if treatment extends beyond 48-72 hours, monitoring blood glucose for hyperglycemia, assessing for superinfection, and checking clinical response after 2-3 days to determine if therapy should continue 3, 4