Is steroid use recommended in this case of shock with hypoglycemia?

Steroid Use in Shock with Hypoglycemia

In a patient with shock and hypoglycemia, low-dose hydrocortisone (≤200 mg/day) may be considered if the shock is septic in nature and requires vasopressor support, but high-dose steroids should be avoided, and the hypoglycemia must be aggressively corrected first with dextrose solutions before steroid administration. 1

Clinical Decision Algorithm

Step 1: Determine the Type of Shock

• If septic shock requiring vasopressors: Low-dose hydrocortisone may be appropriate 1
• If sepsis without shock: Corticosteroids are NOT recommended 1
• If other shock etiologies: Follow traditional adrenal insufficiency guidelines only if indicated 1

Step 2: Address the Hypoglycemia FIRST

• Do NOT use insulin if blood glucose cannot be measured regularly 1
• Correct hypoglycemia immediately with intravenous dextrose before considering steroids 1
• Monitor blood glucose closely as steroids will significantly worsen hyperglycemia once hypoglycemia is corrected 1, 2

Step 3: Steroid Dosing if Indicated for Septic Shock

Low-dose hydrocortisone protocol:

• Use hydrocortisone ≤200 mg/day (typically 200 mg/day divided or continuous infusion) 1
• Prefer continuous infusion over bolus dosing to minimize glucose fluctuations 1
• Do NOT use high-dose steroids (e.g., hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) as they increase mortality risk through infections, hyperglycemia, and gastrointestinal bleeding 1

Step 4: Consider Adrenal Insufficiency

• An inappropriately low random cortisol level (<18 µg/dL) in shock is an indication for steroid therapy per traditional adrenal insufficiency guidelines 1
• Do NOT use ACTH stimulation testing to guide steroid decisions in septic shock 1
• If history of chronic steroid use or known adrenal dysfunction, steroids are indicated regardless 1

Critical Management Considerations

Glucose Monitoring Strategy

• Implement frequent capillary glucose measurements (every 1-2 hours initially) once steroids are started 2
• Target blood glucose 140-180 mg/dL in hospitalized patients 2
• Peak hyperglycemia occurs 7-9 hours after steroid administration, particularly in afternoon/evening 1, 2

Insulin Management with Steroids

• Use a more resistant sliding scale insulin regimen to address steroid-induced insulin resistance 2
• Consider isophane insulin 0.1-0.3 units/kg/day if persistent hyperglycemia develops 2
• When steroids are tapered or discontinued, rapidly reduce insulin to prevent hypoglycemia 2

Duration and Tapering

• Taper steroids when vasopressors are no longer required 1
• Taper over several days rather than abrupt cessation to avoid hemodynamic rebound 1

Common Pitfalls to Avoid

• Never use high-dose steroids as they increase hospital-acquired infections, hyperglycemia, GI bleeding, and delirium without mortality benefit 1
• Do not use hypotonic fluids (glucose solutions) for fluid resuscitation in shock 1
• Avoid etomidate for intubation if steroids will be used, as it suppresses the HPA axis and increases 28-day mortality 1
• Do not underestimate the additive hyperglycemic effects when dextrose solutions and steroids are used simultaneously 2
• Never continue the same insulin regimen after steroid discontinuation as this leads to severe hypoglycemia 2

Special Circumstances

If the patient has pre-existing diabetes or develops steroid-induced hyperglycemia:

• Basal-bolus insulin regimen may be needed at 0.3-0.5 units/kg split 50/50 between long-acting and rapid-acting insulin 1
• Metformin can be added if renal and hepatic function are preserved 1
• Do not use sulfonylureas for steroid-induced hyperglycemia 2