When is hydrocortisone (cortisol) used in patients with septic shock?

Hydrocortisone Use in Septic Shock

Hydrocortisone should only be used in septic shock patients when adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability, at a dose of 200 mg per day. 1

Indications for Hydrocortisone in Septic Shock

Hydrocortisone administration in septic shock follows a specific algorithm:

1. First-line management:

   • Adequate fluid resuscitation
   • Vasopressor therapy to restore hemodynamic stability

2. When to initiate hydrocortisone:

   • Only when first-line measures fail to restore hemodynamic stability
   • Specifically when patients remain hypotensive despite fluid resuscitation and vasopressor therapy 1

3. Contraindications:

   • Do not use hydrocortisone if hemodynamic stability is achieved with fluid resuscitation and vasopressors alone
   • Do not use for sepsis without shock 1

Dosing and Administration

• Recommended dose: 200 mg per day 1
• Administration method: Continuous infusion is preferred over intermittent bolus dosing 1
• Duration: Continue until vasopressors are no longer required, then taper 1
• No ACTH testing needed: The adrenocorticotropic hormone stimulation test is not recommended to identify which patients should receive hydrocortisone 1

Clinical Benefits and Outcomes

Hydrocortisone in vasopressor-dependent septic shock has been shown to:

• Accelerate shock reversal (median 3 days vs 4 days with placebo) 2
• Shorten duration of initial mechanical ventilation 2
• Reduce blood transfusion requirements 2

However, it's important to note that recent high-quality evidence from the ADRENAL trial showed no significant improvement in 90-day mortality (27.9% vs 28.8%, p=0.50) 2.

Special Considerations

• Obesity: BMI does not appear to impact the effects of fixed-dose hydrocortisone on vasopressor requirements or blood pressure in septic shock patients, so dose adjustments based on weight are not necessary 3
• Hyperglycemia risk: Hydrocortisone increases the risk of hyperglycemia, requiring close glucose monitoring 4, 5
• Superinfection risk: There is an increased risk of superinfection, including new sepsis and septic shock 5

Common Pitfalls to Avoid

1. Premature initiation: Starting hydrocortisone before adequate fluid resuscitation and vasopressor optimization
2. Delayed initiation: Waiting too long in refractory shock cases
3. Prolonged use: Not tapering hydrocortisone when vasopressors are no longer required
4. Inappropriate use: Administering in sepsis without shock
5. Inadequate monitoring: Failing to monitor for hyperglycemia and superinfection

By following this evidence-based approach to hydrocortisone use in septic shock, clinicians can optimize outcomes while minimizing potential adverse effects of corticosteroid therapy.