- Relative corticosteroid insufficiency in patients with severe septic shock
- Adrenal insufficiency
- Steroid responsive inflammatory conditions
PRESENTATION AND ADMINISTRATION:
100 mg/2 mL vial plus benzyl alcohol diluent
Reconstitute by pressing down on the plastic activator. This forces the diluent into the lower compartment. Gently agitate to dissolve powder. To withdraw solution, remove the plastic tab covering the stopper. Wipe the top of the stopper with an alcohol swab. Insert drawing up needle through the centre of the stopper until the tip is just visible. Invert vial and withdraw dose.
Reconstituted solutions and solutions with concentrations not exceeding 1 mg/mL are stable for up to 24 hours.
Compatible with the following IV fluids:
Normal saline, 5% Dextrose, Glucose and sodium chloride, Hartmanns
Can be administered by infusion but preferred method in Wellington ICU is by direct IV injection. Reconstituted solution is generally injected undiluted as slow IV push.
Hydrocortisone 5mg and 20 mg tablets (white)
Septic shock: 50 mg QID
Note: many different dosage regimens exist for various indications; for most ICU indications the above dose is appropriate.
DOSAGE IN RENAL FAILURE AND RENAL REPLACEMENT THERAPY:
Dose as in normal renal function
DOSAGE IN PAEDIATRICS:
0.5 - 4 mg/kg QID
Hydrocortisone is a naturally occurring steroid hormone which has glucocorticoid and mineralocorticoid properties
The use of hydrocortisone sodium succinate sterile powder is contraindicated in premature infants as the 100, 250, 500 and 1000 mg ACT-O-VIAL System contains benzyl alcohol. This has been reported to be associated with a fatal 'Gasping Syndrome' in prematurity.
Steroid induced myopathy:
An acute myopathy has been observed with the use of high doses of corticosteroids, most often occurring in patients with disorders of neuromuscular transmission (such as myasthenia gravis), or in patients receiving concomitant therapy with neuromuscular blocking drugs. This acute myopathy is generalised, may involve ocular and respiratory muscles, and may result in quadriparesis. Elevations of creatine kinase may occur. Clinical improvement or recovery after stopping corticosteroids may take weeks to years.
Adrenal-insufficiency due to steroids:
In patients on corticosteroid therapy subjected to unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated.
Corticosteroids may mask some signs of infection, and new infections may appear during their use.
Average and large doses of hydrocortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium. These effects are less likely to occur with the synthetic derivatives except when used in large doses.
There is an enhanced effect of corticosteroids in patients with hypothyroidism and in those with cirrhosis.
Psychic derangements may appear when corticosteroids are used ranging from euphoria, insomnia, mood swings, personality changes, and severe depression to frank psychotic manifestations. Also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids.
No tests in addition to routine ICU tests are required
Drug/Laboratory Test Interactions:
IMPORTANT DRUG INTERACTIONS IN ICU:
Drugs that induce hepatic enzymes such as phenobarbital, phenytoin and rifampin may increase the clearance of corticosteroids and may require increases in corticosteroid dose to achieve the desired response.
Fluid and Electrolyte Disturbances:
Sodium retention, fluid retention, congestive heart failure in susceptible patients, potassium loss, hypokalaemic alkalosis, hypertension
Muscle weakness from steroid myopathy, loss of muscle mass, osteoporosis, tendon rupture (particularly of the Achilles tendon), vertebral compression fractures, aseptic necrosis of femoral and humeral heads, pathologic fracture of long bones
Peptic ulcer with possible perforation and haemorrhage, pancreatitis, abdominal distention, ulcerative oesophagitis, increases in alanine transaminase (ALT, SGPT), aspartate transaminase (AST, SGOT) and alkaline phosphatase have been observed following corticosteroid treatment.
Impaired wound healing, thin fragile skin, petechiae and ecchymoses, facial erythema, increased sweating, may suppress reactions to skin tests
Convulsions, increased intracranial pressure with papilloedema (pseudotumour cerebri) usually after treatment, vertigo, headache
Menstrual irregularities. development of Cushingoid state, suppression of growth in children, secondary adrenocortical and pituitary unresponsiveness (particularly in times of stress as in trauma, surgery or illness), decreased carbohydrate tolerance, manifestations of latent diabetes mellitus, increased requirements for insulin or oral hypoglycaemic agents in diabetics