Adernocortical Insufficiency in Patients with Septic Shock: Incidence and Effect of Steroid Therapy

Introduction: Absolute or relative adrenocortical insufficiency (AI) is relatively common in septic shock patients. In some cases, septic shock refractory to IV fluids and vasopressors may show hemodynamic improvement after steroid therapy.Objectives: To determine the incidence of AI in patients with septic shock, to clarify whether glucocorticoid supplementation is beneficial in patients with septic shock its effect on mortality.Methods: An observational prospective study was performed at Critical Care Department, Cairo University on 50 patients with septic shock who required vasopressor therapy after adequate fluid resuscitation without previous steroid intake. After measurement of baseline total cortisol, the patients were subjected to ACTH stimulation test (250mg). Post-stimuli cortisol levels were drawn 60 minutes after.Adrenal dysfunction (AD) was defined as serum cortisol 20mg/dl with ∆ cortisol (60 min. post ACTH minus baseline) of ≤ 9mg/dl. Functional hypoadrenalism (FH) was defined as serum cortisol 30mg/dl or ∆ cortisol ≤ 9mg/dl. as the presence of either AD or FH. Patients with AI and patients who did not show any hemodynamic improvement after adequate fluid resuscitation and vasopressors therapy were given steroids. The steroid used was hydrocortisone 100mg/8hr till clinical improvement. Results: Fifty pts; 27 males 23 females with mean age 58.6±15.5 and mean APACHE II score 28.0±9.0. The commonest source of infection was multiple sources (32%) followed by abdominal infection (26%), infected wounds (24.0%), chest infection (16%) then urinary tract infection (2%). 48% (24 patients) had negative culture and 52% (26 patients) had +ve culture results. 40.0% (20 patients) with Gram +ve bacteria 12.0% (6 patients) with Gram –ve bacteria. Hyperkalemia on admission was significantly higher in patients with AI (p=0.016). Statistically significant higher incidence of AI in pts with pre-existing liver disease (p=0.026). Steroids were given to 70% (35 patients) as follow: 38% (19 patients) with adrenal dysfunction, 24% (12 patients) with functional hypoadrenalism and 8% (4 patients) were given steroid empirically according to the guidelines of Surviving Sepsis Campaign. Fifteen patients (43%) had initial hemodynamic improvement with no significant effect on mortality whether 10 days or overall mortality. Increased mortality in patients with AI (74.3%) vs those with no AI (53.6%), however it did not reach a statistically significant value, p=0.074. Overall mortality was 80% in all pts.Conclusions: High incidence of AI in patients with septic shock. Initial hemodynamic improvement with steroid therapy. No effect of steroid therapy on mortality reduction.