Endocrine · Topic 10 of 13

Corticosteroids in Critical Illness

Endocrine · corticosteroid pharmacology

Corticosteroids in Critical Illness

Hydrocortisone 200 mg/day speeds shock reversal in vasopressor-dependent septic shock. Know the dose equivalents and who needs stress dosing.

Key numbers

Septic shock: hydrocortisone 200 mg/day IVHC 200 mg/day

Start when norepinephrine ≥ 0.25NE ≥ 0.25 mcg/kg/min

No high-dose, short-course steroids in septic shock> 400 mg/day, < 3 days

Hydrocortisone 20 mg = prednisone 5 mgHC 20 = pred 5 mg

Major surgery: hydrocortisone 100 mg at induction100 mg, then 200 mg/24 h

01 · GiveSeptic shock: hydrocortisone 200 mg/day IV

For adults with septic shock and an ongoing vasopressor requirement, give IV hydrocortisone 200 mg/day as 50 mg every 6 hours or a continuous infusion (Surviving Sepsis 2021; still suggested in 2026).

02 · The ruleStart when norepinephrine ≥ 0.25

Start hydrocortisone when norepinephrine or epinephrine is ≥ 0.25 mcg/kg/min at least 4 hours after vasopressor initiation to hold the target MAP — the SSC definition of ongoing vasopressor requirement.

03 · CalculateHydrocortisone 20 mg = prednisone 5 mg

Equivalent anti-inflammatory doses: hydrocortisone 20 mg = prednisone or prednisolone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg.

What it is

Core idea

Benefit: faster shock reversal, not clear survivalIn septic shock, low-dose corticosteroids shorten time to shock resolution and add vasopressor-free days, without a clear effect on mortality, and increase neuromuscular weakness.

Causes & risk factors

Why it happens

Over 3–4 weeks above physiologic dose suppresses HPAMore than 3–4 weeks above the physiologic dose (hydrocortisone 15–25 mg, prednisone 4–6 mg, dexamethasone 0.25–0.5 mg daily) can suppress the HPA axis; such patients need stress dosing during critical illness or surgery.

Diagnosis & monitoring

Work-up

Monitor glucose, sodium, infection and weaknessWatch for hyperglycemia, hypernatremia and fluid retention, secondary infection, ICU-acquired weakness, and delirium or psychosis during critical-illness steroid therapy.

Management

Orders

Major surgery: hydrocortisone 100 mg at induction must knowMajor surgery in adrenal insufficiency or untested steroid exposure: hydrocortisone 100 mg IV at induction, then 200 mg/24 h (infusion or 50 mg every 6 h) while NPO, then double oral dose for 48 h.

Fludrocortisone add-on is optionalHydrocortisone plus enteral fludrocortisone lowered 90-day mortality in APROCCHSS, while hydrocortisone alone did not in ADRENAL; adding fludrocortisone is reasonable but not required by guidelines.

Minor procedures: double the oral doseFor minor procedures or local anesthesia in at-risk patients, give an oral stress dose for the day — for example hydrocortisone 40 mg total in three doses or prednisone 10 mg.

Red flags & don'ts

Avoid harm

No high-dose, short-course steroids in septic shock avoidSCCM 2024 recommends against high-dose, short-duration corticosteroids (> 400 mg/day hydrocortisone equivalent for < 3 days) in septic shock; use low-dose hydrocortisone for several days instead.

The rules

Know these

Don't wait for a cortisol levelIn septic shock the decision to give hydrocortisone rests on vasopressor dependence, not on a random cortisol or cosyntropin test; the trials behind the recommendation did not require adrenal testing.

Give steroids in severe community-acquired pneumoniaSCCM 2024 strongly recommends corticosteroids for hospitalized adults with severe bacterial CAP and makes no recommendation for less severe CAP.

Consider steroids in ARDSSCCM 2024 conditionally suggests corticosteroids for critically ill adults with ARDS; no specific agent, dose or duration is endorsed, though methylprednisolone 1 mg/kg/day is a commonly used regimen.

Courses under 3–4 weeks need no taperGlucocorticoid courses shorter than 3–4 weeks can be stopped without a taper regardless of dose; longer courses are tapered toward a physiologic dose.

Hydrocortisone or dexamethasone?

Commonly confused

Dose equal to prednisone 5 mg	20 mg
Mineralocorticoid effect	Significant
Septic shock regimen	200 mg/day IV (50 mg every 6 h or infusion)

More detail

Reference

Show 4 reference facts

Optimal duration is uncertain: trials gave hydrocortisone 200 mg/day for up to 7 days (ADRENAL, APROCCHSS) or for 5 days followed by a 6-day taper (VANISH).

Etomidate inhibits the final enzymatic step of cortisol synthesis (11β-hydroxylase), and even a single induction dose raises the risk of transient adrenal insufficiency in critically ill patients; ketoconazole acts similarly.

The 2008 critical-care criteria (random cortisol < 10 mcg/dL or a rise < 9 mcg/dL after cosyntropin) were not widely adopted and were dropped in 2017; altered cortisol binding in critical illness limits cortisol testing.

When long-acting glucocorticoids (dexamethasone, betamethasone) are no longer needed, switch to a shorter-acting agent (hydrocortisone or prednisone) before tapering.

Pearl

Septic shock steroids are low-dose and longer: 200 mg/day of hydrocortisone, never a 400-plus milligram pulse.

Sources · Evans L et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Med 2021;47:1181–1247 · Prescott HC et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 — SCCM guideline page (IV corticosteroids: suggest, low certainty) · Chaudhuri D et al. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, ARDS, and Community-Acquired Pneumonia (SCCM). Crit Care Med 2024;52:e219–e233 — SCCM guideline page · Critical illness-related corticosteroid insufficiency: latest pathophysiology and management guidelines. Acute Crit Care 2024 · Parente L. Deflazacort: therapeutic index, relative potency and equivalent doses versus other corticosteroids. BMC Pharmacol Toxicol 2017;18:1 (Table 3: equivalent glucocorticoid doses and mineralocorticoid potency) · Beuschlein F et al. ESE/Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2024 (physiologic dose equivalents; Table 8 perioperative stress dosing) · Critical illness-related corticosteroid insufficiency (CIRCI) — an overview of pathogenesis, clinical presentation and management. Front Endocrinol 2024 · Merck Manual Professional — Primary Adrenal Insufficiency (Addison Disease): mineralocorticoids not needed with high-dose hydrocortisone · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).