In a 62‑year‑old man with hypertension, poorly controlled type II diabetes mellitus, community‑acquired pneumonia and septic shock who is receiving hydrocortisone 200 mg per day (50 mg IV every 6 hours), what serious steroid‑related complications, other than worsening hyperglycemia, should be anticipated?

Serious Steroid-Related Complications in Septic Shock Beyond Hyperglycemia

In this 62-year-old man receiving hydrocortisone 200 mg/day for septic shock, the most important steroid-related complications to anticipate—beyond hyperglycemia—are neuromuscular weakness (ICU-acquired weakness), hypernatremia, hypokalaemia, psychiatric disturbances (insomnia, mania, psychosis), superinfections, and gastrointestinal complications including occult perforation.

Critical Metabolic and Electrolyte Disturbances

Monitor and treat hypernatremia and hypokalaemia as routine complications of hydrocortisone therapy in septic shock. 1

• Hypernatremia occurs frequently with hydrocortisone due to mineralocorticoid effects and requires regular serum sodium monitoring, especially beyond 48-72 hours of treatment 2
• Hypokalaemia results from the mineralocorticoid activity of hydrocortisone and necessitates routine electrolyte monitoring and replacement 1
• These electrolyte disturbances are considered "less important" patient outcomes by guideline panels compared to mortality, but they require active management to prevent complications 1

Neuromuscular Weakness (ICU-Acquired Weakness)

Corticosteroids may increase the risk of neuromuscular weakness, which can compromise functional independence and delay recovery. 1

• Seven RCTs evaluating weakness found that corticosteroids may increase this risk by a small amount (low-quality evidence) 1
• The mechanism involves toxic effects on nerve and muscle cells, compounded by corticosteroid-induced hyperglycemia 1
• This complication is likely underestimated in trials because most relied on investigator identification rather than prospective systematic evaluation 1
• The absolute harm from neuromuscular weakness will be greater in sicker patients like this one with multiple comorbidities 1
• Consider early physical therapy as a preventive and therapeutic measure 1

Psychiatric and Neurologic Complications

Hydrocortisone can cause insomnia and lead to psychiatric adverse effects including mania and psychosis in predisposed individuals. 1

• These neuropsychiatric effects are well-documented FDA-labeled adverse events 3
• Monitor for behavioral changes, sleep disturbances, and mood alterations throughout treatment
• The risk may be heightened in elderly patients and those with pre-existing psychiatric conditions

Superinfections

Superinfections, including new sepsis and septic shock, are important patient-centered outcomes that must be monitored. 1

• Myocardial infarction, stroke, and superinfections were identified as important outcomes by guideline panels 1
• Meta-analyses of low-dose hydrocortisone regimens (200 mg/day) indicate no significant increase in superinfection rates, whereas high-dose regimens (>400 mg/day) are associated with excess harm 4
• The current dose of 200 mg/day falls within the safe range, but vigilance for new infections remains essential 4
• Infection surveillance is recommended during corticosteroid treatment because steroids blunt the febrile response 5

Gastrointestinal Complications

Steroids should be used with caution given this patient's multiple risk factors, as they may increase the risk of gastrointestinal perforation, and signs of peritoneal irritation may be minimal or absent. 3

• The FDA label specifically warns that steroids increase perforation risk in patients with active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and non-specific ulcerative colitis 3
• Critical pitfall: Signs of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids may be minimal or absent 3
• Maintain high clinical suspicion for occult abdominal catastrophe even without classic peritoneal signs

Cardiovascular and Renal Considerations

Sodium retention with resultant edema and potassium loss may occur, requiring cautious use in patients with congestive heart failure, hypertension, or renal insufficiency. 3

• This patient's pre-existing hypertension increases vulnerability to fluid retention and electrolyte disturbances 3
• Monitor for signs of volume overload and worsening hypertension throughout treatment

Adrenal Suppression and Withdrawal Complications

Corticosteroid-induced adrenal suppression is duration-dependent; patients receiving longer courses (>14 days) require gradual tapering and may need evaluation of hypothalamo-pituitary-adrenal axis function. 1

• Inflammation may recur after discontinuing corticosteroid therapy, especially when stopped abruptly 1
• Carefully monitor all patients after discontinuing corticosteroids for recurrence of inflammation and signs of adrenal insufficiency 1
• In patients who deteriorate after stopping corticosteroids (development of shock or need for mechanical ventilation), reinitiating therapy could be helpful 1
• Taper gradually over 6-14 days when vasopressors are no longer required rather than stopping abruptly 2, 5

Monitoring Strategy

Implement routine sepsis monitoring including bloodwork, with specific attention to:

• Blood glucose levels (target <150 mg/dL) 6
• Serum sodium for hypernatremia 2
• Serum potassium for hypokalaemia 1
• Clinical assessment for neuromuscular weakness 1
• Behavioral and psychiatric changes 1
• Signs of new infection or superinfection 1
• Occult gastrointestinal complications 3