Hydrocortisone in Septic Shock
Hydrocortisone should only be administered in septic shock when adequate fluid resuscitation and vasopressor therapy are unable to restore hemodynamic stability, at a dose of 200 mg per day. 1, 2, 3
Indications for Hydrocortisone in Septic Shock
- Hydrocortisone is indicated specifically for patients with septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy (vasopressor-unresponsive septic shock) 1, 2, 3
- The Surviving Sepsis Campaign guidelines recommend against using hydrocortisone in septic patients who do not have shock 4, 2
- Hydrocortisone should be considered when patients remain on moderate to high-dose vasopressors despite adequate fluid resuscitation 1, 3
Dosage and Administration
- The recommended dose is 200 mg/day of intravenous hydrocortisone 4, 1, 3
- Administration can be either as a continuous infusion (preferred) or in divided doses 1, 2
- Treatment should continue for at least 3 days at full dose, or longer as clinically indicated 1, 3
- Hydrocortisone should be tapered when vasopressors are no longer required rather than stopping abruptly to avoid rebound inflammation 4, 1, 5
Diagnostic Testing
- The ACTH stimulation test is not recommended to identify patients who should receive hydrocortisone (grade 2B) 4, 1, 2
- Random cortisol levels may be useful for diagnosing absolute adrenal insufficiency but not for relative adrenal insufficiency in septic shock patients 2
Clinical Benefits and Evidence
- Hydrocortisone has been shown to improve shock reversal and reduce time on vasopressors 6, 7
- Early initiation of hydrocortisone (within 3 hours) may reduce the time needed to discontinue vasopressors compared to later initiation 7
- Studies show contradictory results regarding mortality benefit, with most evidence suggesting no significant impact on overall mortality 6, 8
- Physiologic-dose steroids can reduce vasopressor requirements and improve time of shock resolution 6
Tapering Considerations
- Approximately 50% of patients receive a hydrocortisone taper in clinical practice, with the most common method being a reduction in frequency (56.8%) 5
- Typical taper duration is about 2 days (range 1-3 days) 5
- Patients who receive a taper may require an increase in vasopressor rate at 24 hours (37.4% vs 21.3%) compared to those who don't receive a taper 5
Potential Risks and Adverse Effects
- Increased risk of superinfection, including new sepsis and septic shock 6, 8
- Other potential adverse effects include hyperglycemia, hypernatremia, and gastrointestinal bleeding 1, 3
- Regular monitoring of blood pressure, serum electrolytes, and blood glucose is recommended 1, 3
Common Pitfalls to Avoid
- Using corticosteroids in sepsis without shock provides no benefit and is not recommended 1, 2, 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 2
- Abrupt discontinuation of corticosteroids can lead to deterioration from a reconstituted inflammatory response 1
- Fludrocortisone addition to hydrocortisone has not shown significant benefits in shock-free days or mortality 9