Outcome of septic shock patients with relative adrenal insufficiency

Introduction

Septic shock may be associated with relative adrenal insufficiency. A replacement therapy with low doses of corticosteroids has been proposed to treat septic shock.

Objective

To describe the outcome of a cohort of septic shock patients with a treatment strategy guided by a short corticotropin test.

Design and setting

An observational and prospective cohort of severe septic shock patients treated in a general ICU of a university hospital.

Materials and methods

Thirty-three patients who fulfilled criteria for severe septic shock. In all patients a short corticotropin test (250 μg) with cortisol measured at 0, 30 and 60 min was performed. The response to the test was considered whenever the difference between baseline cortisol and pick cortisol was greater than 9 mg/dl. Low-dose corticosteroids (hydrocortisone 50 mg, intravenously, 6/6 hours) was given to all patients and maintained only when the patient was a non-responder.

Main outcome measure

Twenty-eight-day mortality.

Results

The total mortality rate was 65% (21/32). The non-survivors where older (68.5 ± 11.5 vs 53.9 ± 20.2, P = 0.014), and had a higher baseline cortisol (27.5 ± 17.7 vs 17.0 ± 12.9 μg/dl, P = 0.043). APACHE II score, pick cortisol, delta cortisol and albumin where not different. There were 15 responders and 17 non-responders to the corticotropin test. In non-responders, the mortality rate was 64% (11/17) and in responders it was 66% (10/15). Responders had a higher baseline cortisol (29.1 ± 20.7 vs 19.2 ± 11.1 mg/dl, P = not significant), higher pick cortisol (45.4 ± 21.9 vs 23.7 ± 10.3 μg/dl, P = 0.001) and higher delta cortisol (16.3 ± 5.9 vs 4.7 ± 2.3 μg/dl, P < 0.001). Age, APACHE II score and albumin were similar. Vasopressor therapy was withdrawn in 20 patients and eight patients were responders (40%). Among 12 patients not weaned from vasopressors, seven (58%) were responders. Hypoalbuminemic (albumin < 2.5 g/dl) and non-hypoalbuminemic patients had no differences among measured variables. However, 60% (15/25) of hypoalbuminemic but only 28% (2/7) of normoalbuminemic patients were non-responders.

Conclusions

Mortality rates among responders and non-responders were equivalent and may indicate a beneficial effect of low-dose hydrocortisone. Hypoalbuminemia may influence the response to the corticotropin test once most hypoalbuminemic patients were non-responders.