Hydrocortisone

Hydrocortisone - In the critically ill patient, adrenocortical insufficiency should be considered when an inappropriate amount of inotropic support is required. Baseline cortisol levels and short synacthen test do not predict response to steroid.In patients who demonstrate a normal short synacthen test,but yet show a dramatic response to steroid, it is possible that the abnormality lies in altered receptor function or glucocorticoid resistance rather than abnormality of the adrenal axis. Baseline cortisol levels and short synacthen test are worthwhile to assess hypothalamic pituitary adrenal axis dysfunction versus steroid unresponsiveness. Available as the sodium succinate or the phosphate ester

Uses
Adrenal insufficiency (primary or secondary)
Prolonged resistant vasopressor dependent shock
Severe bronchospasm
Hypersensitivity reactions (p. 243)
Fibroproliferative phase of ARDS (unlicensed)
Adjunct in Pneumocystis carinii pneumonia (see co-trimoxazole and pentamidine)

Contraindications
Systemic infection (unless specific anti-microbial therapy given)

Administration
• Adrenal insufficiency
Major surgery or stress: IV 100–500 mg 6–8 hourly
Minor surgery: IV 50 mg 8–12 hourly
Reduce by 25% per day until normal oral steroids resumed or maintained on 20 mg in the morning and 10 mg in the evening IV

• Prolonged resistant vasopressor dependent shock
Initial dose 50 mg IV bolus, 6 hourly for 5 days, then 50 mg 12 hourly for 3 days, then 50 mg daily for 3 days, then stop or 50 mg IV bolus followed by infusion of 10 mg/h for up to 48 hours

• Fibroproliferative phase of ARDS
IV infusion: 100–200 mg 6 hourly for up to 3 days, then dose reduced gradually

• Adjunct in Pneumocystis carinii pneumonia (see co-trimoxazole and pentamidine)

IV: 100 mg 6 hourly for 5 days, then dose reduced to complete 21 days of treatment
The steroid should be started at the same time as the co-trimoxazole or pentamidine and should be withdrawn before the antibiotic treatment is complete. Reconstitute 100 mg powder with 2 ml WFI. Further dilute 200 mg and made up to 40 ml with sodium chloride 0.9% or glucose 5% (5 mg/ml)

How not to use hydrocortisone
Do not stop abruptly (adrenocortical insufficiency)

Adverse effects
Perineal irritation may follow IV administration of the phosphate ester
Prolonged use may also lead to the following problems:
• increased susceptibility to infections
• impaired wound healing
• peptic ulceration
• muscle weakness (proximal myopathy)
• osteoporosis
• hyperglycaemia

Cautions
Diabetes mellitus
Concurrent use of NSAID (increased risk of GI bleeding)