Impact of continuous versus bolus low-dose hydrocortisone application on blood glucose in septic shock patients

Tight glycemic control in critically ill patients has been shown to reduce ICU and hospital morbidity and mortality [1]. Adjunctive low dose hydrocortisone (HC) therapy in septic shock (200–300 mg/day) might impair tight glycemic control. The degree of metabolic impairment is possibly influenced by the way of HC administration. However, recent Surviving Sepsis Campaign guidelines do not favour either continuous HC administration (cHC) or bolus HC administration (bHC) (4 × 50 mg or 3 × 100 mg) [2]. The purpose of this observational study was to investigate the effects of bHC on blood glucose (Glc) levels in patients with septic shock. The protocol was approved by the local ethics committee. Sixteen patients receiving cHC (200 mg/day) were included. The course of Glc after discontinuing cHC followed by administration of a bolus of 50 mg HC was investigated. Glc values were recorded from charts 12 hours prior to bHC application, straight before bolus application (baseline), and hourly during a 6-hour period. Afterwards, cHC was resumed and Glc measured three times 4 hours apart. Insulin dosage was not adjusted as long as Glc remained <180 mg/dl. Nutritional support was not changed during study period. Mean Glc calculated from all values 12 hours prior to baseline was 131 mg/dl (mean, 95% confidence interval: 121, 142). At baseline, Glc was 128 mg/dl (114, 141). Glc increased significantly from baseline until 6 hours (P < 0.01, analysis of variance) with peak levels of 154 mg/dl (132, 178) after 5 hours (P < 0.05 compared with baseline), and returned to baseline values after 14 hours. The presented data indicate that a bolus of 50 mg HC significantly aggravates impairment of glucose homeostasis. It is conceivable that repetitive HC application three or four times per day would make adequate insulin therapy and glucose monitoring much more time consuming and difficult. In conclusion, although a comparative study on outcome between cHC and bHC does not exist, it seems prudent to administer HC as a continuous infusion in septic shock patients in order to maintain normoglycemia in these patients as tight as possible.

Figure 1

(abstract P389)