Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
47-year-old woman with a history of alcoholism is evaluated in the emergency department at night for abdominal bloating and pain, fever, confusion, and shortness of breath. She has a mean arterial blood pressure of 64 mm Hg, which decreases despite fluid administration. Chest radiograph shows a pattern consistent with noncardiogenic pulmonary edema and her PaO2 to FiO2 ratio is 145. Paracentesis shows an ascitic fluid leukocyte count of 545/μL (0.545 × 109/L) with 95% polymorphonuclear cells. Antibiotic therapy and aggressive fluid resuscitation and supplemental oxygen are provided. The following morning, the patient is still exhibiting signs of septic shock.
Which of the following corticosteroid therapy would be most appropriate for this patient?
A High-dose hydrocortisone (1 to 2 g/d)
B Hydrocortisone, 50 mg every 6 hours and continue until response to ACTH stimulation test is normal
C Corticosteroids not indicated
D Hydrocortisone, 50 mg every 6 hours for 14 days
Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
Correct Answer = B)
Key Points
* Patients with severe sepsis and refractory shock despite adequate fluid resuscitation should be treated with replacement-dose corticosteroids.
* High-dose corticosteroid therapy is ineffective and may be harmful in patients with severe septic shock and relative adrenal insufficiency.
This patient should be treated with hydrocortisone, 50 mg every 6 hours, and the therapy should be stopped if response to ACTH stimulation test is normal. The subgroup of septic patients who are currently treated with stress-replacement-dose corticosteroids are those with severe sepsis and refractory shock despite adequate fluid resuscitation. The study by Annane and colleagues enrolled patients with refractory shock despite fluids and vasopressors. In that study, patients who had a dampened response to cosyntropin stimulation showed a survival advantage in the intervention group who received both hydrocortisone, 50 mg intravenous every 6 hours, and fludrocortisone (53% 28-day mortality in corticosteroid group vs. 63% in the placebo group). Patients who had a normal adrenal axis (as evidenced by a serum cortisol response to cosyntropin stimulation of >10 mg/dL) actually had a nonsignificant but slightly higher mortality rate. To further add to the controversy, it was shown by Hamrahian and colleagues that total cortisol levels may be qualitatively different than a patient's free cortisol, which is the metabolically active measure in a fashion analogous to total vs. free thyroid hormone. High-dose corticosteroids have been shown to be ineffective and even harmful in several randomized controlled trials from the 1980s and 90s.
Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
IS DOSAGE ASKED IN REAL EXAM---
