Shock Syndromes I

Patient Case

A 55-year-old man presents to the medical ICU with presumed urosepsis. His medical history is significant

for congestive heart failure with a baseline ejection fraction of 20%. In the medical ICU, his vital signs are

as follows: blood pressure 69/45 mm Hg, heart rate 84 beats/minute, respiratory rate 32 breaths/minute,

and temperature 100.6°F (38.1°C). Blood cultures are obtained, and piperacillin/tazobactam is initiated. A

central venous catheter shows CVP 18 mm Hg and Scvo2 70%. Which is the most appropriate initial vaso-

pressor for this patient?

despite fluid administration and vasopressors.

Corticosteroids are an attractive option for patients with septic shock because of their anti-

inflammatory effects (through inhibition of nuclear factor κB) and ability to improve blood pressure

response to catecholamines (through up-regulation of adrenergic receptors and potentiation of

vasoconstrictor actions).

Use of corticosteroids for patients with septic shock has been a source of controversy for years.

In studies of short courses of high-dose corticosteroids (typically at doses of 30 mg/kg of

methylprednisolone or greater) in patients with sepsis and septic shock, corticosteroids did not

improve patient outcomes.

conflicting findings on mortality.

In a French trial of patients with septic shock and vasopressor-unresponsive shock (i.e.,

inability to increase SBP above 90 mm Hg for 1 hour despite fluids and vasopressors), patients

randomized to low-dose hydrocortisone and fludrocortisone had improved survival in a time-

to-event analysis (HR 0.71; 95% CI, 0.53–0.97). The mortality benefit with corticosteroids was

limited to patients unable to increase their cortisol concentration by more than 9 mcg/dL in

response to ACTH administration (nonresponders).

ii.

In a larger, multicenter Corticosteroid Therapy of Septic Shock (CORTICUS) study, which

had less-stringent inclusion criteria than the earlier-noted French trial, hydrocortisone

administration was not associated with improved survival in ACTH nonresponders (28-day

mortality 39.2% vs. 36.1%, p=0.69).

iii.

The Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock

(ADRENAL) trial randomized 3800 patients to hydrocortisone or placebo. 90-day mortality

did not differ between the hydrocortisone or placebo groups (27.9% vs. 28.8%, OR 0.95; 95%

CI, 0.82–1.10; p=0.50). However, patients randomized to hydrocortisone had quicker time

to shock resolution (3 vs. 4 days; p<0.001). A subgroup analysis of patients who received

hydrocortisone on the basis of time from shock onset to randomization showed improvement

in death at 90 days in patients who received hydrocortisone within 6–12 hours (OR 0.71; 95%

CI, 0.54–0.94).