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/or admitted under the Paediatric Endocrinology Team with appropriate steroid replacement.
The classic triad for primary 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
Blood tests (for known at risk patients on steroids already):
- 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 rapidly
for short illness
- 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
- Those already on high dose steroids (daily Prednisone
etc) should continue their medication.
The key is not to stop or go to IV.
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 already sufficient (see Table 3 for potency compared to hydrocortisone).
Review once off steroid in view of possible ACTH deficiency from surgery (can be weeks to months later)
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' (eg for gastroscopy) 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% glucose.
- 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, on steroids (fludrocortisone and
hydrocortisone), acute vomiting, abdominal pain, temperature of
Administer 100 mg hydrocortisone IM/IV followed by a continuous infusion of 100mg/m2/day until clinically stable. (Fludrocortisone not normally needed when on IV steroids of such doses)
- 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: 26 January 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Endocrinology
- Author(s): Craig Jefferies
- Owner: Craig Jefferies
- Editor: Greg Williams
- Review frequency: 2 years
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