HYDROCORTISONE

In the critically ill patient, adreno cortical 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 hypothalami c –pituitary–adrenal axis dysfunction versus steroid unresponsiveness.  Available as the sodium succinate or the phosphate ester

 Uses     

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

Contraindications   
Systemic infection (unless specifi c anti-microbial therapy given)   
 Administration   
•   Adrenal insuffi  ciency   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days of treatment    The steroid should be started at the same time as the co-trimoxazole or pentamidine and should be withdrawn before the antibiotic treatment is complete   Reconstitute 100 mg powder with 2 ml WFI.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 insuffi  ciency)   
 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)     
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