If this patient develops septic shock from a bile leak in the postanesthesia care unit (PACU), should steroids be withheld or administered?

If this patient develops septic shock from a bile leak in the postanesthesia care unit (PACU), should steroids be withheld or administered?

Administration of steroids for the treatment of septic shock has long been debated. Although it has been recognized that steroid administration could restore vascular responsive-ness to catecholamine administration and allow the with-drawal of vasopressor therapy, clinical trials have generally revealed that greater potential harm than benefit occurred.

Recently Annane et al. (2002) performed a landmark mul-ticenter, randomized, double-blind, and placebo-controlled trial to assess whether “low” doses of corticosteroids improve survival from septic shock. In this investigation, patients in septic shock underwent a cosyntropin stimula-tion test. Patients were randomized to receive either hydro-cortisone 50 mg by intravenous bolus every 6 hours and fludrocortisone 50 μg orally once daily or a placebo.

Of the 299 patients, 229 were found to be relatively adrenal-insufficient and classified as “nonresponders.” A nonresponse to the cosyntropin stimulation test was defined as a rise in the serum cortisol level of 9 μg/dL or less. Patients who were nonresponders (i.e., adrenal-insufficient) had a statistically significant (P = 0.04) lowered mortality rate when administered steroids (53% vs. 63% at 28 days, and 58% vs. 70% at the end of the ICU stay in the steroid vs. placebo group). Patients who were responders (i.e., adrenal-sufficient) had a statistically insignificant increased mortality when administered steroids (61% vs. 53% at 28 days and 69% vs. 59% at the end of the ICU stay in the steroid vs. placebo group).

Based primarily on this investigation, the Society of Critical Care Medicine now recommends hydrocortisone administration in the treatment of vasopressor-resistant shock.

While final conclusive evidence is lacking, this author recommends performing an ACTH stimulation test fol-lowed by administration of hydrocortisone 50 mg intra-venously every 6 hours to all patients requiring vasopressors in the management of presumed septic shock. After obtaining the results of the stimulation test (which usually takes 24–48 hours), steroids will be continued for 7 days in patients with a baseline plasma cortisol level of less than 20 μg/dL, or a rise from the baseline level of less than 9 mg/dL. Patients who do not meet these criteria will have their steroids discontinued.