Hydrocortisone Therapy in Septic Shock

Introduction to Hydrocortisone Use

The American College of Critical Care Medicine recommends administering hydrocortisone 200 mg/day intravenously in patients with septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy, with a strength of evidence considered moderate to high 1, 2, 3

Reserve hydrocortisone exclusively for vasopressor-unresponsive septic shock after adequate fluid resuscitation has been completed, as recommended by the Society of Critical Care Medicine 1, 2
Initiate hydrocortisone when patients require moderate-to-high dose vasopressors (>0.1 μg/kg/min norepinephrine equivalent), based on guidelines from the American College of Critical Care Medicine 2
Do not administer hydrocortisone in sepsis without shock, as it provides no benefit and may cause harm, according to the American College of Critical Care Medicine 2, 3

Absolute adrenal insufficiency (peak cortisol after ACTH stimulation <18 μg/dL) with catecholamine-resistant shock is an absolute indication for hydrocortisone therapy, as stated by the Society of Critical Care Medicine 4, 5
Patients with purpura fulminans, Waterhouse-Friderichsen syndrome, prior chronic steroid therapy, or pituitary/adrenal abnormalities should receive hydrocortisone, according to the American College of Critical Care Medicine 4, 5

Administer 200 mg/day hydrocortisone for at least 3 days at full dose, as recommended by the American College of Critical Care Medicine 1, 2, 3
Use low-dose, long-duration therapy (<400 mg/day) and avoid high-dose short courses, as advised by the Society of Critical Care Medicine 2
Taper hydrocortisone gradually when vasopressors are no longer required, according to the American College of Critical Care Medicine 1

Initial stress dose for pediatric patients is 50 mg/m²/24 hours, as recommended by the American Academy of Pediatrics 5
Approximately 25% of children with septic shock have absolute adrenal insufficiency, according to the Society of Critical Care Medicine 5, 3

Hyperglycemia is the most common adverse effect requiring monitoring, as stated by the American College of Critical Care Medicine 2
Increased risk of superinfection, including new sepsis and septic shock, is a potential adverse effect, according to the Society of Critical Care Medicine 1
Monitor blood glucose levels, signs of new infection, serum sodium, and hemodynamic parameters for shock reversal, as recommended by the American College of Critical Care Medicine 5

Avoid etomidate for intubation in septic shock patients, as it suppresses the hypothalamic-pituitary-adrenal axis and may increase mortality, according to the American College of Critical Care Medicine 1
Do not use hydrocortisone in sepsis without shock, and do not rely on ACTH stimulation testing to determine treatment eligibility, as advised by the Society of Critical Care Medicine 2, 1

The American Association for the Study of Liver Diseases (AASLD) recommends administering hydrocortisone 200 mg/day intravenously for at least 7 days or until ICU discharge in patients with septic shock and suspected adrenal insufficiency who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy 6, 7
Hydrocortisone is indicated for patients with septic shock requiring moderate-to-high dose vasopressors (≥0.1 μg/kg/min norepinephrine equivalent) despite adequate fluid resuscitation, with earlier shock reversal and potential mortality benefit demonstrated in the ADRENAL and APROCCHSS trials 6, 7
Patients with cirrhosis and relative adrenal insufficiency (cortisol increase <9 μg/dL after Synacthen) may benefit from hydrocortisone, as this condition occurs in 49% of decompensated cirrhosis patients and is associated with significantly higher 90-day mortality (26% vs. 10%) 6, 7

The recommended dosing for hydrocortisone is 200 mg/day intravenously, using either 50 mg IV every 6 hours or 200 mg continuous IV infusion over 24 hours, with some guidelines suggesting doses up to 300 mg/day for severe cases 6, 7, 8
The 2024 AASLD guidelines specifically recommend either 50 mg IV q6h or 200-mg infusion for 7 days or until ICU discharge 6, 7

Early initiation of hydrocortisone (≤3 hours) versus late (>3 hours) may reduce time to vasopressor discontinuation, and the speed of treatment initiation influences prognosis 8