From the Guidelines
Hydrocortisone is recommended for patients with septic shock who require vasopressors despite adequate fluid resuscitation, at a dose of 200 mg per day. The use of hydrocortisone in septic shock is supported by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, which suggests that IV hydrocortisone should be used in patients with septic shock that is not responsive to fluid and vasopressor therapy 1. The guidelines recommend against using hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.
Key Points
- Hydrocortisone should be initiated within the first 6 hours of shock onset for maximum benefit.
- The standard dosing is 200 mg per day, typically given as a continuous infusion.
- Treatment duration is usually 5-7 days, with gradual tapering rather than abrupt discontinuation if used for more than 3 days.
- Blood glucose levels should be monitored regularly during treatment as hyperglycemia is a common side effect.
- Hydrocortisone works by reducing inflammation, stabilizing cell membranes, and enhancing the sensitivity of blood vessels to vasopressors, thereby improving hemodynamic stability.
Benefits and Risks
The use of hydrocortisone in septic shock has been shown to reduce the risk of death at 28 days compared with placebo, particularly when used at low doses (<400 mg of hydrocortisone or equivalent per day) for a longer duration of treatment (3 or more days at the full dose) 1. However, corticosteroids should not be routinely used in sepsis without shock as they provide no survival benefit in this population and may increase complications such as secondary infections.
Monitoring and Management
Regular monitoring of blood glucose levels is necessary during hydrocortisone treatment, as hyperglycemia is a common side effect. The treatment should be tapered gradually rather than discontinued abruptly if used for more than 3 days. The use of hydrocortisone in pediatric patients with septic shock is not well established and requires further research.
From the Research
Role of Hydrocortisone in Sepsis Management
The use of hydrocortisone (cortisol) in the management of sepsis is a topic of ongoing debate. Several studies have investigated the effects of hydrocortisone on septic shock, with varying results.
- The study by 2 found that prolonged therapy with lower doses of hydrocortisone (200-300 mg for 5-7 days or longer) in septic shock revealed beneficial effects, including improved shock reversal and reduced inflammation.
- In contrast, the study by 3 suggested that high-dose corticosteroid therapy is associated with increased harm, while physiologic-dose corticosteroids may decrease the need for vasopressors.
- The study by 4 found that hydrocortisone therapy did not reduce the risk of septic shock within 14 days in patients with severe sepsis who were not in septic shock.
- The study by 5 found that early initiation of hydrocortisone (within 3 hours) reduced the time needed to discontinue vasopressors and improved shock reversal, but did not affect ICU mortality or length of stay.
- The study by 6 found that hydrocortisone did not improve survival or reversal of shock in patients with septic shock, although it hastened reversal of shock in patients in whom shock was reversed.
Key Findings
- Hydrocortisone may be beneficial in patients with septic shock, particularly those with relative adrenal insufficiency (RAI) or peripheral cortisol resistance 2, 3.
- The optimal timing of hydrocortisone initiation is uncertain, but early initiation may be beneficial in reducing the time needed to discontinue vasopressors 5.
- Hydrocortisone does not appear to improve survival in patients with septic shock, although it may hasten reversal of shock in some patients 6.
- The use of hydrocortisone may be associated with an increased risk of superinfection, including new sepsis and septic shock 6.