Stress Steroid Management
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High Risk Groups
High-Risk groups for Adrenal Crisis are:
Primary adrenal deficiency:
- Congenital Adrenal Hyperplasia
- Addison's disease or adrenal hypoplasia
Secondary (pituitary) ACTH deficient conditions:
- Hypopituitarism (congenital/idiopathic)
- Septo-optic dysplasia or midline CNS abnormalities
Recent treatment with high dose synthetic steroids for prolonged periods
All children at risk of adrenal insufficiency should be discussed with and admitted under the Paediatric Endocrinology Team with appropriate steroid replacement.
The classic triad for adrenal crisis: ↓ serum Na, ↑ serum K, and ↓ serum Glucose
Symptoms seen in Adrenal Crisis: (not all have to be present)
- Dehydration, shock
- GI symptoms (Vomiting, Diarrhea, Abdominal Pain, Constipation)
- Hypotension (postural drop).
- Lethargy, weakness
- Electrolytes (particularly Na, K, glucose)
- +/-cap gas.
- Monitor vital signs (BP, Pulse, Temperature)
- Tachycardia with postural drop
Principles of Management
- Increased Cortisol is needed in times of stress
In normal subjects increases approximately 5+ fold during any major physical stress such as illness, anesthesia and surgery.
- Goal: to replace appropriate cortisol response in
children who are adrenally insufficient
- The preferred route is IV (or IM); hydrocortisone is
the steroid of choice.
- A continuous IV infusion is ideal
- Intermittent boluses 6 x per day (4 hourly) are another option
- High doses (stress) of hydrocortisone also provide full
The exception is dexamethasone: has no significant mineralocorticoid effect.
- Stress doses of hydrocortisone can be reduced
- Back to simple replacement doses as the patient recovers.
- "Tapering" the dose is not usually needed in this setting.
- Don't forget to treat the underlying cause of the
Consider occult infection/appendicitis/UTI etc
A - Severely Unwell:
Unstable / Crisis OR Unwell (vomiting, diarrhoea, drowsy), unable to tolerate oral hydrocortisone
- Bolus IV fluids: 10-30 ml/kg 0.9% saline, then maintenance 0.9% saline + 5% dextrose.
- Start IV steroids
Bolus - Hydrocortisone: 75-100 mg/m2 IV (or IM) - then
Infusion - Hydrocortisone 55-100mg/m2/day until stable.
- Body surface area: √(height (cm) x weight (kg)/3600) or use BSA calculator.
Table 1 gives rapid estimates of hydrocortisone doses.
Table 1: Rapid Estimates of Hydrocortisone Dose if Weight or BSA not available
|Age||Initial bolus dose of hydrocortisone succinate (IM or IV|| Hydrocortisone
(50 mg hydrocortisone in 50 ml 0.9% saline)
|0 - 6 months||12.5 mg||1ml/hr : infants
2 ml/hr: pre-schoolers
3 ml/hr: older children
|6mo - 5 years||25 mg|
|5 -10 years||50 mg|
|>10 years||100 mg|
Presumed adrenal insufficient patient undergoing CNS tumour resection:
Dexamethasome given for raised ICP is sufficient (see Table 3 for potency compared to hydrocortisone).
Review once off steroid in view of possible ACTH deficiency from surgery
Stable with fever, reduced activity:
If able to tolerate oral hydrocortisone: give 50 mg/m2/day
e.g.: Give 5x (five times) the patient's normal total daily dose hydrocortisone, as 4-5 divided doses (breakfast, lunch, afternoon tea, dinner, bedtime)
Gastroenteritis: Stable with mild
If able to tolerate oral fluids start oral hydrocortisone 50mg/m2/day as above
If unable to tolerate oral fluids give IV/IM hydrocortisone (see 'A' above)
Respiratory, ear infection, no fever, vomiting or
diarrhoea, and looks well
Continue normal maintenance doses of steroid.
No Fever >38 degrees, not on antibiotics.
Elective surgical procedures
Simple elective surgery
Can be managed by increased oral hydrocortisone for 24-48 hours. (2-3x)
Often an oral dose of hydrocortisone at the onset of the 'Nil by mouth' period can suffice: discuss with anaesthetist regarding when Nil by mouth period starts
For more acute surgery or prolonged illness/surgery
Table 2: Peri-operative Stress Steroids
|Weight (kg)||Single dose Hydrocortisone
PO - prior to being NBM
|Rate of infusion INTRA- and
50 mg hydrocortisone in 50 ml 0.9% saline (ml/hr = mg/hr)
|3 - 10||25 mg||1|
|10 - 20||50 mg||2|
- Maintenance IV fluid rate of 0.9% NaCl with 5% dextrose.
- If weight is unknown dosing can be based on age:
En route to surgery, prior to anaesthesia:
0-3 yrs : Hydrocortisone 25 mg IV bolus, then 50 mg/m2 (~25 mg) infusion for remaining 24 hrs
3-12 yrs : Hydrocortisone 50 mg IV bolus, then 50 mg/m2 (~50-60 mg) infusion for remaining 24 hrs
12 yrs : Hydrocortisone 100 mg IV bolus, then 50 mg/m2 )~100 mg) infusion for remaining 24 hrs
- Once stable: switch to maintenance oral hydrocortisone (~10mg/m2/day).
- 12 year old male with CAH, acute vomiting, abdominal pain,
temperature of 38.5, hypotensive:
Administer 100 mg hydrocortisone IM/IV followed by a continuous infusion of 100mg/m2/day until clinically stable.
- 9 month old male with congenital hypopituitarism with upper
respiratory infection and fever of 38.3°C. Usual medication
hydrocortisone 2 mg am, 1.25 mg midday, and 1.25 mg at night. So
total is 5 mg/day.
Give 5 mg hydrocortisone x 5 times per day until fever resolves, then go back to maintenance dose.
See GP to investigate cause of fever.
|Glucocorticoid effect in relation to hydrocortisone/cortisol=1.0||Sodium Retention Effect Equivalent to 0.1 mg Florinef PO||Stress dose for individual glucocorticoid preparations equivalent to 100mg Cortisol PO|
|Prednisone||4 - 6||50||25 mg|
|Prednisolone||6 - 8||50||20 mg|
|Methylprednisolone (Solumedrol)||6 - 8||0||15-20 mg|
|Dexamethasone||80 to 120||0||1.5 mg|
|9a-Fluorocortisone (Florinef)||~None; but 15x mineralocorticoid effect||0.1||N/A|
References and Further Reading
Pediatric Endocrinology, Sperling, 3rd ed. 2008
Practical Endocrinology and Diabetes in Children 2nd ed. 2006
Pediatric Practice: Endocrinology, Michael Kappy, David Allen, Mitchell Geffner, 2010,
Did you find this information helpful?
- Date last published: 01 October 2013
- Document type: Clinical Guideline
- Services responsible: Paediatric Endocrinology
- Author(s): Craig Jefferies, Anita Azam
- Owner: Craig Jefferies
- Editor: Greg Williams
- Review frequency: 2 years
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