Should we switch to intravenous (IV) hydrocortisone based on the Cape Cod study?

Hydrocortisone in Septic Shock: Insights from the Cape Cod Study

Based on the recent Cape Cod study, IV hydrocortisone should be considered for patients with severe community-acquired pneumonia in the ICU, as it demonstrated a significant reduction in 28-day mortality (6.2% vs 11.9%) compared to placebo 1.

Current Guidelines on Corticosteroids in Septic Shock

The Surviving Sepsis Campaign guidelines recommend:

• IV hydrocortisone should NOT be used to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy can restore hemodynamic stability 2
• IV hydrocortisone at 200 mg/day should be considered ONLY when hemodynamic stability cannot be achieved with adequate fluid resuscitation and vasopressor therapy (Grade 2C) 2
• When hydrocortisone is given, continuous infusion is preferred (Grade 2D) 2
• Hydrocortisone should be tapered when vasopressors are no longer required 2

Cape Cod Study Findings

The Cape Cod study (2023) provides important new evidence:

• Demonstrated a 5.6 percentage point absolute reduction in 28-day mortality with hydrocortisone in severe community-acquired pneumonia 1
• Reduced need for mechanical ventilation (18.0% vs 29.5%) in patients not already intubated 1
• Reduced need for vasopressors (15.3% vs 25.0%) in patients not already receiving them 1
• Similar rates of hospital-acquired infections and GI bleeding between groups 1

Practical Administration of IV Hydrocortisone

For patients meeting criteria for hydrocortisone therapy:

• Dosing: 200 mg/day IV hydrocortisone 2, 3
• Administration method: Continuous infusion is preferred 2, 3
• Duration: At least 3 days at full dose or until vasopressors are no longer required 3
• Tapering: Gradual tapering rather than abrupt discontinuation 3

Monitoring and Adverse Effects

• Hyperglycemia: Occurs in approximately 90.9% of patients; monitor blood glucose levels 3
• Hypernatremia: Monitor serum electrolytes 3
• Secondary infections: Monitor for signs of new infections 3
• Hemodynamic parameters: Assess response to therapy 3

Special Considerations

1. ACTH stimulation testing is NOT recommended to identify which patients should receive hydrocortisone 2, 3

2. Stress dosing for patients on chronic steroids:

   • For patients on chronic medium/high-dose glucocorticoids, consider switching to IV hydrocortisone during acute illness 2
   • For patients on 10 mg prednisone daily, consider IV hydrocortisone 25 mg twice daily 2
   • For patients on high-dose glucocorticoids, consider IV hydrocortisone 50 mg three times daily 2

3. Avoid high-dose corticosteroids for septic shock management 3

Algorithm for Decision Making

1. Initial management: Start standard septic shock management with fluids and vasopressors
2. Assess response: Evaluate hemodynamic stability after adequate fluid resuscitation
3. Consider hydrocortisone if:
   • Patient requires escalating or multiple vasopressors despite adequate fluid resuscitation
   • Patient has severe community-acquired pneumonia requiring ICU admission (based on Cape Cod study)
4. Administer: 200 mg/day IV hydrocortisone as continuous infusion
5. Monitor: Blood glucose, electrolytes, hemodynamic response
6. Taper: When vasopressors are no longer required

The Cape Cod study provides compelling new evidence for considering IV hydrocortisone in severe community-acquired pneumonia, even if it represents a shift from previous guidelines that restricted hydrocortisone use to vasopressor-dependent septic shock.