A 56-year-old woman with hypertension, rheumatoid arthritis, and gastroesophageal reflux disease presents with perforated diverticulitis. Her home medications include lisinopril 10 mg, prednisone 15 mg, and omeprazole 40 mg. After emergent small bowel resection she was admitted to the ICU with low-dose norepinephrine. She is initially treated with piperacillin-tazobactam, and her home prednisone is continued. She remains vasopressordependent despite 30 mL/kg of normal saline and the addition of vasopressin.
Which of the following treatment regimens is most appropriate at this time?
A. Change antibiotics to cefepime and metronidazoleCorrect Answer: B
This patient likely has a suppressed hypothalamic-pituitary-adrenal axis due to long-term exogenous glucocorticoid intake. These patients do well with normal activities but may be unable to mount an adequate steroid response to the stress of surgery or critical illness. Typical patients are those with chronic autoimmune or inflammatory diseases (asthma, ulcerative colitis, rheumatoid arthritis), or those with underlying primary or secondary adrenal insufficiency who take chronic steroid supplementation. Although past recommendations have indicated that all patients on chronic steroids require “stress dose,” it is now generally accepted to be necessary only for patients taking 5 mg or greater of prednisone, per day, for more than 3 weeks. In addition to their typical daily maintenance dose, patients should receive additional steroids commensurate with the anticipated stress. A reasonable approach is to use 50 mg of hydrocortisone followed by 25 mg every 8 hours for surgeries with minor (eg hernioplasty, colonoscopy) or moderate surgical stress (eg total joint replacement, cholecystectomy). A higher initial dose of 100 mg followed by 50 mg every 8 hours is recommended for surgeries with major surgical stress such as cardiac surgery. A higher dose may be needed for critical illness–related corticosteroid insufficiency. In contrast to nonendocrine diseases, patients with organic primary or secondary adrenal insufficiency are not capable of augmenting their serum cortisol levels at all, and these patients should always receive supplemental glucocorticoids
There is no indication that the current antibiotic regimen is insufficient as it adequately covers for abdominal sepsis, and cultures have not shown any resistant organisms. She has received adequate fluid resuscitation for septic shock, and there is no clinical reason to bolus further. Although epinephrine may be added to support her blood pressure, it will not treat the underlying cause of adrenal insufficiency.
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