Adrenal exhaustion in septic patients with vasopressor dependency

Abstract

Purpose The use of low-dose corticosteroids for patients with septic shock who remain vasopressor dependent after adequate fluid resuscitation is recommended, but there is lack of agreement on how to diagnose relative adrenal insufficiency (RAI) and when to start steroid supplementation among these patients. This case series reports changes in cortisol concentrations during the course of vasopressor-dependent septic shock. Methods Observational study was performed at a university hospital medical intensive care unit. Consecutive adult patients with vasopressor-dependent septic shock admitted to the medical intensive care unit were studied. Clinical data, cortisol concentrations, and dose of vasopressor agents at different times during the course of septic shock were recorded and reported as mean ± SD. Results Thirteen patients were included. Mean age was 59 ± 15 years. Mean basal nonstimulated cortisol level was 41.7 ± 30.9 μg/dL (within 24 hours of intensive care unit admission in all but 2 patients). Steroids were initiated in 8 patients and then discontinued after cortisol values were obtained and RAI was ruled out. Because of inability to discontinue vasopressor support, cortisol testing was repeated after 6.2 ± 4.8 days of initial assessment. Repeated concentrations were 10.0 ± 6.3 μg/dL ( P < .001). Steroids were then reinitiated, and resolution of vasopressor dependence was achieved 1.5 ± 1.4 days later. Conclusions Adrenal function in the critically ill is a dynamic process, and an appropriate initial adrenal response does not preclude later development of RAI.