A 75-year-old man is admitted to the ICU with septic shock. Broad spectrum antibiotics are initiated, and he undergoes fluid resuscitation. Despite receiving 5 L of lactated ringers, he remains hypotensive requiring high-dose norepinephrine and vasopressin infusions. Cardiac ultrasound reveals hyperdynamic ventricular function without other abnormalities.
Which of the following statements regarding administration of systemic corticosteroids is most appropriate for this patient?
A. Perform an ACTH stimulation test and give methylprednisolone if adrenally insufficientCorrect Answer: C
The surviving sepsis guidelines recommend low-dose steroids in patients who are fluid-resuscitated in vasopressor-dependent shock who are unable to reach their target MAP goal. It is not necessary to perform an ACTH stimulation test. Steroid use is associated with improved MAP and shorter duration of vasopressor use. This is a low-strength recommendation, but steroids may be warranted in this decompensating patient.
Early research using high-dose methylprednisolone (supra-physiologic) did not show improved survival and possible harm. Subsequent trials using physiologic doses arrived at conflicting results. The study by Annane and colleagues (2002) and the APROCCHSS trial (2018) showed that patients with septic shock had faster reversal of shock and decreased mortality after receiving low-dose hydrocortisone and fludrocortisone. On the other hand, the CORTICUS trial in 2008 and the ADRENAL trial in 2018 found a faster resolution of shock, but no difference in 28-day mortality with hydrocortisone administration. Thus, evidence is mixed against recommending routine use in patients who are adrenally insufficient. Guidelines do not recommend routine ACTH testing as it may be unreliable in critical illness and may be affected by numerous medications.
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