Surgical Critical Care Hydrocortisone Replacement Guideline

Relative adrenal insufficiency/ critical illness related corticosteroid insufficiency (CIRCI) is very common among critical care patients. In trauma patients, prevalence of this entity can be up to 80% among severely injured patients.
It has been repeatedly shown that trauma patients who have CIRCI do worse compared to those with similar presentation and do not have CIRCI. Although hydrocortisone replacement has not been studied rigorously to consistently show a mortality reduction, studies did show that hydrocortisone replacement in these patients could lead to reduced pressor support, reduced ICU LOS, reduced ventilation times and reduction in pneumonia incidence. The adverse effects of low dose hydrocortisone replacement (200mg/day) is usually hyperglycemia. Given that the benefits of hydrocortisone replacement outweigh potential risks, a guideline has been designed to best select patients who might benefit the most from this intervention.

All patients admitted to the TICU on vasoactive (pressors) support for shock, the following should be carried out:

1. Obtain baseline total cortisol levels
2. Give 50mg Hydrocortisone IV

The continuation of hydrocortisone will be based on the cortisol levels.

• If total cortisol is 15mcg/dl or more, then patient is unlikely to have adrenal insufficiency, and no further hydrocortisone should be given.
• If total cortisol is less than 15ug/dl, then patient should continue to receive hydrocortisone 50mg q6hrs for 7 days minimum.
• Weaning of hydrocortisone should be done gradually by reducing total daily hydrocortisone dosage by 50mg every 48 hours

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