What is the role of stress dose steroids, such as hydrocortisone (corticosteroid), in managing vasoplegia associated with hypotension?

Role of Stress Dose Steroids in Managing Vasoplegia

Stress dose steroids (hydrocortisone) should be used in vasoplegia only when adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability, at a dose of 200 mg per day administered as a continuous infusion rather than bolus dosing. 1

Definition and Pathophysiology of Vasoplegia

Vasoplegia is characterized by:

• Persistent low systemic vascular resistance
• Normal or high cardiac index
• Profound vasodilation
• Hypotension refractory to fluid resuscitation 2

Vasoplegia commonly occurs in:

• Septic shock
• Post-cardiac surgery
• Cardiac failure
• Other critical conditions 2

First-Line Management of Vasoplegia

Before considering corticosteroids, the following should be implemented:

1. Adequate fluid resuscitation to restore intravascular volume
2. Vasopressor therapy with:
   • Norepinephrine as first-choice vasopressor 1
   • Consider adding vasopressin (up to 0.03 U/min) to raise mean arterial pressure or decrease norepinephrine requirements 1
   • Epinephrine as an additional agent if needed 1

Role of Stress Dose Steroids

When to Use Corticosteroids

Hydrocortisone should be considered only when:

• Adequate fluid resuscitation has been performed
• Vasopressor therapy is ongoing
• Hemodynamic stability cannot be achieved with the above measures 1

Dosing and Administration

When indicated:

• Use hydrocortisone at 200 mg per day 1
• Administer as continuous infusion rather than bolus injections to avoid peaks in blood glucose 1
• Taper steroids when vasopressors are no longer required 1

Evidence Quality and Recommendations

The recommendation for using hydrocortisone in vasoplegic shock is based on weak evidence:

• Weak recommendation, low quality of evidence 1
• Grade 2C in earlier guidelines 1

ACTH Stimulation Testing

• ACTH stimulation testing is not recommended to identify patients who should receive hydrocortisone 1
• An inappropriately low random cortisol level (<18 μg/dL) in a shock patient may be considered an indication for steroid therapy 1

Special Considerations

Duration of Therapy

• No definitive recommendation on optimal duration of hydrocortisone therapy 1
• Studies have used both fixed-duration protocols and clinically guided regimens 1
• Taper steroids when vasopressors are no longer required 1

Contraindications

• Corticosteroids should not be administered for sepsis in the absence of shock 1

Potential Side Effects

• Hyperglycemia
• Hypernatremia
• Secondary infections 1

Alternative Therapies for Refractory Vasoplegia

If vasoplegia persists despite standard therapy including steroids, consider:

• Methylene blue
• Hydroxocobalamin
• Angiotensin II
• Vitamin C and thiamine 2, 3, 4, 5

Clinical Pitfalls to Avoid

1. Delayed recognition of vasoplegia can lead to prolonged shock and increased mortality
2. Overreliance on steroids without adequate fluid resuscitation and vasopressor therapy
3. Failure to taper steroids when vasopressors are no longer required
4. Using etomidate for intubation in septic shock patients, as it can cause adrenal suppression 1
5. Continuing steroids too long after resolution of shock, increasing risk of secondary infections

Monitoring During Steroid Therapy

• Blood pressure and vasopressor requirements
• Blood glucose levels
• Serum sodium
• Signs of secondary infection

By following this algorithmic approach to the use of stress dose steroids in vasoplegia, clinicians can optimize outcomes while minimizing potential adverse effects of corticosteroid therapy.