A 56-year-old woman with hypertension, rheumatoid arthritis, and gastroesophageal reflux disease is admitted to the ICU after undergoing a bowel resection for perforated diverticulitis. Her home medications include lisinopril 10 mg, prednisone 15 mg, and omeprazole 40 mg. She is treated with piperacillin-tazobactam and receives adequate fluid resuscitation over the next 24 hours but continues to require vasopressors for hypotension.
Given a concern for adrenal insufficiency, which of the following steroids is most appropriate to administer to this patient?
A. PrednisoneCorrect Answer: D
This patient has vasopressor-resistant septic shock despite adequate IV fluid resuscitation which may be due to adrenal insufficiency. Current guidelines on critical illness–related corticosteroid insufficiency recommend IV hydrocortisone <400 mg/d for ≥3 days in patients with septic shock that is not responsive to fluid resuscitation and requires moderate- to high-dose vasopressor therapy. Hydrocortisone is the synthetic equivalent to the physiologic final active compound, cortisol, so treatment with hydrocortisone directly replaces cortisol independently from metabolic transformation. In these large doses it provides both glucocorticoid and mineralocorticoid coverage. A potential disadvantage of hydrocortisone administration is that diagnostic testing of adrenal function cannot be performed while receiving the medication.
Dexamethasone does not have any intrinsic mineralocorticoid activity and therefore would not provide full repletion. Fludrocortisone would not be an adequate choice as it is pure mineralocorticoid and does not have any glucocorticoid activity. Additional mineralocorticoid replacement is not needed as long as the dose of cortisol exceeds 50 mg daily. If a patient is completely adrenally insufficient, then fludrocortisone should also be administered. Prednisone and cortisone are typically avoided in critically ill patients because they require hydroxylation to create the active compound (prednisone to prednisolone and cortisone to cortisol). In addition, these are only available for oral administration, and their use is limited in critical care where enteral absorption may be compromised.
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