From the Guidelines
Hydrocortisone should be used in septic shock patients who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy, at a dose of 200 mg per day. This recommendation is based on the most recent and highest quality study available, which suggests that hydrocortisone can be beneficial in patients with refractory septic shock 1. The use of hydrocortisone in septic shock is supported by several studies, including a French multicenter RCT that showed significant shock reversal and reduction of mortality rate in patients with relative adrenal insufficiency 1.
Key Points
- Hydrocortisone is recommended for patients with septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy
- The standard regimen is 50 mg IV every 6 hours or 200 mg/day as a continuous infusion for 5-7 days, with gradual tapering rather than abrupt discontinuation
- Hydrocortisone works by reducing inflammation, stabilizing cell membranes, enhancing vasopressor sensitivity, and maintaining vascular integrity
- The medication addresses relative adrenal insufficiency that often occurs during severe sepsis, where the body cannot produce sufficient cortisol to meet increased demands
Rationale
The response of septic shock patients to fluid and vasopressor therapy seems to be an important factor in selection of patients for optional hydrocortisone therapy 1. The use of hydrocortisone in septic shock is also supported by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, which suggests that hydrocortisone can be used in patients with septic shock who are unresponsive to fluid and vasopressor therapy 1.
Evidence
The evidence for the use of hydrocortisone in septic shock is based on several studies, including a French multicenter RCT that showed significant shock reversal and reduction of mortality rate in patients with relative adrenal insufficiency 1. Another study published in Critical Care Medicine in 2017 also supports the use of hydrocortisone in septic shock patients who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy 1.
Clinical Implications
The use of hydrocortisone in septic shock has significant clinical implications, including the potential to reduce mortality and improve outcomes in patients with refractory septic shock. However, the decision to use hydrocortisone should be made on a case-by-case basis, taking into account the individual patient's response to fluid and vasopressor therapy, as well as their overall clinical condition 1.
From the Research
Role of Hydrocortisone in Septic Shock
- Hydrocortisone is used as an adjunctive treatment for septic shock, particularly in patients who are vasopressor-dependent 2, 3, 4.
- The use of hydrocortisone in septic shock is heterogeneous, and current clinical trials yield conflicting results 2.
- Studies have compared the effects of hydrocortisone and methylprednisolone in patients with septic shock, with some finding similar effects 3, 5, 6 and others finding differences in clinical outcomes 2, 4.
Clinical Outcomes
- Patients who received hydrocortisone had higher lactate levels and Acute Physiology and Chronic Health Evaluation (APACHE) III scores, and longer vasopressor duration compared to those who did not receive hydrocortisone 2.
- Hospital mortality was higher in the hydrocortisone group, but after multivariable adjustment, no association between receipt of hydrocortisone and hospital mortality was detected 2.
- Time to shock reversal was similar between hydrocortisone and methylprednisolone groups in some studies 3, 5, while others found differences in ICU mortality and length of stay 5, 6.
Prescribing Patterns
- There is significant variability in the prescribing patterns of hydrocortisone in septic shock, with different interpretations of the guidelines 4.
- The majority of intensivists defined "poorly responsive to vasopressors" as the presence of two vasopressors, and required patients to be off vasopressors prior to altering the corticosteroid dose 4.
- Self-described prescribing patterns from intensivists closely matched their actual behavior, suggesting variability is due to differing interpretations of the guidelines themselves, rather than a deficit in knowledge translation 4.