EFFECT OF LOW DOSES OF HYDROCORTISONE IN PATIENT WITH SEPTIC SHOCK AND RELATIVE ADRENAL INSUFFICIENCY: 3 DAYS VERSUS 7 DAYS TREATMENT.
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Abstract:
Division of pulmonary and Critical Care Medicine, Ilsan Paik Hospital, Goyang-si, South Korea (Huh) Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, South Korea (Lim, Koh, Hong)Adrenocortical Insufficiency
Primary Adrenal Insufficiency
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BACKGROUND:
Sepsis is a global disease burden and it accounts for more than half of all the ICU admissions. The mortality of sepsis and septic shock patients is quite high which ranges between 20 to 40%. The research into target directed therapy of septic shock lead to the discovery of upregualtion of hypothalamo-pituitary-adrenal axis in septic chock and also the pathogenesis of adrenal insufficiency in septic shock patients. There were very limited data in the Indian literature with regards to the incidence of adrenal insufficiency in septic shock which prompted us to take up this study.
OBJECTIVES:
1. To assess the incidence of adrenal insufficiency in patients with septic shock.
2. To assess the correlation between serum cortisol levels and mortality.
METHODS:
A study population was selected based on patients admitted to the IMCU with septic shock who meet the criteria for septic shock according to the SEPSIS-3 (2016). 50 patients were studied. It was an observational and prospective study. They were started on empirical steroid therapy and blood drawn and sent for Serum cortisol levels. Once the results came, if they are found to be adrenal insufficient steroids continued for 7 days and then tapered and stopped. If they are normal, steroids are discontinued. The other parameters that were analyzed include age and sex distribution, comorbidities, source of sepsis, organisms causing sepsis, vasopressor requirement, mechanical ventilation requirement, CRP positivity and Outcome of the patients.
RESULTS:
Out of 50 patients, 38% (n=22) were found to have adrenal insufficiency. The mortality rate in the first week of sepsis was 59% in the adrenal insufficiency group and 40.9% in the sufficient group. There was statistically significant high mortality in the both very low and very high cortisol groups. The mortality rate was 59% in patients with cortisol levels 40mcg/dL, which was attributed to the tissue resistance to cortisteroids in sepsis. There were significant increase in vasopressor requirement and the need for mechanical ventilation in the adrenal insufficiency group.
CONCLUSIONS:
There was a high percentage of absolute adrenal insufficiency (38%) in our study population. The rate of relative adrenal insufficiency due to defects in HPA axis could be still high. We were not able to assess the relative adrenal insufficiency as our access to ACTH injections were very limited. The both ends of the spectrum values of serum cortisol were associated with significantly high mortality. Thus it makes it essential to measure cortisol levels in septic shock before giving them steroid replacements.
Surviving Sepsis Campaign
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Sepsis and septic shock represent important causes of morbidity and mortality in children, and adrenal dysfunction may play a role in the cardiovascular and immunological response. According to existing reports, the incidence of adrenal dysfunction in critically ill children varies significantly between 4 and 52% of patients. This article reviews the concept of adrenal insufficiency and the role it may play in a pediatric septic shock. Also discussed are the diagnosis, prognosis, and treatment of adrenal insufficiency in septic shock in adults and children. Finally, the latest recommendations about steroid use in pediatric septic shock are summarized.
Organ dysfunction
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Objectives: The Surviving Sepsis Campaign suggests giving hydrocortisone to septic patients only if their “blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy.” Because the definition of “poorly responsive” is not provided, the purpose of this study was to identify prescribing triggers for hydrocortisone in septic shock. Design: Retrospective chart review of patients with septic shock over 17 months, who received hydrocortisone, followed by a survey of all intensivists who attended in the study ICUs to determine whether provider attitudes matched clinical practice. Setting: Eight ICUs in an academic hospital and a hybrid academic/community hospital. Patients: A total of 155 patients with septic shock in whom vasopressors were initiated and hydrocortisone was prescribed. Measurements and Main Results: Ninety-nine patients (64%) were already receiving two vasopressors before hydrocortisone was prescribed. An additional 22 patients were on a single high-dose vasopressor prior to corticosteroid initiation. Of patients who survived to have their hydrocortisone dose changed, 57% had their corticosteroids tapered, whereas 43% were abruptly discontinued. Seventy-six percent of patients were no longer on vasopressors when the first dosing change was made. Twenty-seven out of 36 intensivists (75%) completed the survey. The majority (72%) defined “poorly responsive to vasopressors” as the presence of two vasopressors, and 70% stated that they required patients to be off vasopressors prior to altering the corticosteroid dose. Conclusions: Significant variability exists when corticosteroids are prescribed for septic shock, with the most common interpretation in our institution of “poorly responsive to fluid resuscitation and vasopressor therapy” being the presence of two vasopressors. The method and timing of corticosteroid discontinuation also differed among providers. Self-described prescribing patterns from intensivists closely matched their actual behavior, suggesting variability is due to differing interpretations of the guidelines themselves, rather than a deficit in knowledge translation.
Surviving Sepsis Campaign
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Recent studies show that children who die from fulminant meningococcaemia have very low cortisol:adrenocorticotrophic hormone (ACTH) ratios within the first 8 h of presentation to emergency facilities compared with survivors. This observation supports the possibility that adrenal insufficiency may contribute to rapid cardiovascular collapse in these children. In recent years, the use of hydrocortisone treatment has become increasingly popular in the care of adult and paediatric patients with septic shock. In this review, the classical adrenal insufficiency literature is presented and the existing rationale for using titrated hydrocortisone treatment (2-50 mg/kg/day) to reverse catecholamine-resistant shock in children who have absolute adrenal insufficiency (defined by peak cortisol level <18 microg/dl after ACTH challenge) or pituitary, hypothalamic or adrenal axis insufficiency is provided. In addition, the concept of relative adrenal insufficiency (basal cortisol >18 microg/dl but a peak response to ACTH <9 microg/dl) is reviewed. Although there is a good rationale supporting the use of 7 days of low-dose hydrocortisone treatment (about 5 mg/kg/day) in adults with this condition and catecholamine resistant septic shock, the paediatric literature suggests that it is prudent to conduct more studies before recommending this approach in children.
Primary Adrenal Insufficiency
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Society of Critical Care Medicine; 28th Educational and Scientific Symposium; San Francisco, California, USA; January 23-27, 1999: Poster Presentations: Poster Hall
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