What is the role of hydrocortisone (cortisol) in the management of septic shock?

Role of Hydrocortisone in Septic Shock Management

Hydrocortisone should not be used in septic shock patients if adequate fluid resuscitation and vasopressor therapy successfully restore hemodynamic stability, but should be administered at a dose of 200 mg per day when hemodynamic stability cannot be achieved with these initial measures. 1, 2, 3

Indications for Hydrocortisone in Septic Shock

• Hydrocortisone is indicated only in patients with septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy (vasopressor-unresponsive septic shock) 1, 2
• Hydrocortisone should not be administered to patients with sepsis who do not have shock 2, 4
• The recommended dose is 200 mg/day of hydrocortisone, which can be administered either as a continuous infusion or in divided doses 1, 2, 3

Evidence for Efficacy

• Studies show contradictory results regarding mortality benefit:
  • Some systematic reviews found a significant reduction in 28-day mortality with prolonged low-dose steroid treatment in adult septic shock patients 1
  • Other analyses revealed no statistically significant difference in mortality 1, 5, 6
• Both reviews confirmed improved shock reversal with low-dose hydrocortisone 1, 5
• The HYPRESS trial demonstrated that hydrocortisone does not prevent progression to septic shock in patients with severe sepsis without shock 4
• The ADRENAL trial showed that while hydrocortisone did not reduce 90-day mortality, it did lead to faster resolution of shock and shorter duration of initial mechanical ventilation 6

Administration Guidelines

• The standard dose is 200 mg/day of hydrocortisone 1, 2, 3
• Some evidence suggests that a lower dose of 100 mg/day might reduce hyperglycemia while maintaining efficacy for shock reversal 7
• Continuous infusion is preferred over bolus administration 2, 3
• Treatment should continue for at least 3 days at full dose 3
• Hydrocortisone should be tapered gradually when vasopressors are no longer required rather than stopped abruptly 1, 2, 3

Diagnostic Testing

• The ACTH stimulation test is not recommended to identify patients who should receive hydrocortisone (grade 2B) 1, 2, 3
• Random cortisol levels may be useful for diagnosing absolute adrenal insufficiency but not for relative adrenal insufficiency in septic shock patients 1
• An inappropriately low random cortisol level (<18 µg/dL) in a patient with shock would be considered an indication for steroid therapy along traditional adrenal insufficiency guidelines 1

Potential Benefits and Risks

Benefits:

• Faster shock reversal 1, 5, 6
• Shorter duration of initial mechanical ventilation 6
• Reduced need for blood transfusions 6

Risks:

• Hyperglycemia 3, 7
• Increased risk of superinfection, including new sepsis and septic shock 1, 5
• Potential for gastrointestinal bleeding 3, 7
• Hypernatremia 3
• Psychiatric effects 3

Common Pitfalls to Avoid

• Using hydrocortisone in patients with sepsis without shock provides no benefit and should be avoided 2, 4
• Abrupt discontinuation of corticosteroids can lead to deterioration from a reconstituted inflammatory response 3
• Etomidate use for intubation can suppress the hypothalamic-pituitary-adrenal axis and may be associated with increased mortality when used before application of low-dose steroids 1
• Overreliance on the ACTH stimulation test for determining who should receive hydrocortisone therapy 1, 2

In conclusion, hydrocortisone has a specific role in the management of septic shock that is unresponsive to adequate fluid resuscitation and vasopressor therapy. While it may not reduce mortality, it does lead to faster shock reversal and can be an important component of the management strategy for these critically ill patients.