Pulmonary Disease

Answer 5 Vasopressor-dependent septic shock. An inappropriate cortisol response is not uncommon in patients with septic shock. Low-dose IV corticosteroids (hydrocortisone 200-300 mg/day) are recommended in patients with vasopressor-dependent septic shock.5 However, steroids should not be used in the absence of vasopressor requirement. Higher doses of corticosteroids have been shown to be harmful in severe sepsis.6 The use of adrenal function tests to guide decisions on corticosteroid therapy is considered a reasonable approach.7 An absolute incremental increase of 9 µg/dL at 30 or 60 minutes after administration of 250 µg of corticotropin was found as the best cutoff value to distinguish between adequate adrenal response (responders) and relative adrenal insufficiency (nonresponders).8 Another approach is to use IV dexamethasone 4 mg every 6 hours until a low-dose corticotropin stimulation test can be performed; dexamethasone does not interfere with the cortisol assay but will interfere with adrenal axis response. Corticosteroids may then be continued in nonresponders and discontinued in responders.9 REFERENCES 5. Rivers EP, Gaspari M, Saad GA, et al. Adrenal insufficiency in high-risk surgical ICU patients. Chest 2001; 119:889-96. 6. Bone RC, Fisher CJ, Clemmer TP. A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med 1987;317:653-8. 7. Keh D, Sprung CL. Use of corticosteroid therapy in patients with sepsis and septic shock: an evidence-based review. Crit Care Med 2004;32(11 Suppl):S527-33. 8. Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000; 283:1038-45. 9. Annane D. Cortisol replacement for severe sepsis and septic shock: what should I do? Crit Care 2002;6:190-1. Click here to return to the questions

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