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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)
  • Syncope
  • Fever
  • Tachycardia
  • Hypoglycemia
  • Hypotension (postural drop).
  • Acidosis
  • Lethargy, weakness


Blood tests:

  • Electrolytes (particularly Na, K, glucose)
  • Calcium
  • FBC
  • +/-cap gas.

Clinical tests:

  • Monitor vital signs (BP, Pulse, Temperature)
  • Tachycardia with postural drop

Principles of Management

  1. 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.
  2. Goal: to replace appropriate cortisol response in children who are adrenally insufficient
  3. 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
  4. High doses (stress) of hydrocortisone also provide full mineralocorticoid effect.
    The exception is dexamethasone: has no significant mineralocorticoid effect.
  5. Stress doses of hydrocortisone can be reduced rapidly
    - Back to simple replacement doses as the patient recovers.
    - "Tapering" the dose is not usually needed in this setting.
  6. Don't forget to treat the underlying cause of the stress
    Consider occult infection/appendicitis/UTI etc 

Management Details

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 Infusion
(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

Moderately Unwell

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 diarrhea:
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)

Mildly Unwell

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 PRE-operatively
PO - prior to being NBM 
Rate of infusion INTRA- and POST-operatively:
50 mg hydrocortisone in 50 ml 0.9% saline (ml/hr = mg/hr) 
3 - 10  25 mg   1
10 - 20  50 mg   2
>20  100 mg   3
  • 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).


  1. 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.
  2. 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.

Steroid Potency

Table 3: Steroid Potency

  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 
Cortisol (Hydrocortisone) 20 100mg
Cortisone  0.8  20 125 mg 
Prednisone  4 - 6  50  25 mg 
Prednisolone 6 - 8  50  20 mg 
Methylprednisolone (Solumedrol)  6 - 8  0 15-20 mg 
Dexamethasone  80 to 120  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,

Australasia Paediatric Endocrine Group - Adrenal Gland

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Document Control

  • 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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