Stress Dose

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taken2

taken2

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Hey guys...please I need help !!!!
What is stress dosing and why do they give stress dose of hydrocortisone to septic shock patients ?
I have read a couple of articles but still trying to piece together the informations. I will appreciate any help.
 
Read the section in the Surviving Sepsis guidelines on supplemental corticosteroid use for a primer. If you still have questions after that, CORTICUS and that French trial should clear the rest up.
 
Basically, my experience is that septic shock patients who don't respond to fluids, pressors, and early goal directed therapy at my ED are usually adrenally insufficient.

Give them stress dose steroids (i.e. hydrocortisone 100mg iv x1) and some perk up.

The reversal of shock occurs in the majority of my patients, but the M/M outcomes at the end are similar per studies done all over the world.

The short of it:
Sepsis>adrenally insufficient>low cortisol/steroid hormones>give stress dose> patients perk up.

Last night, I had a patient who was given 6 LITERS of 0.9NS fluid and still his blood pressure was 80/50... gave hydro and sent him to the MICU w/ a central line for pressor support (dopa/levophed).
 
pinipig523 said:
Basically, my experience is that septic shock patients who don't respond to fluids, pressors, and early goal directed therapy at my ED are usually adrenally insufficient.

Give them stress dose steroids (i.e. hydrocortisone 100mg iv x1) and some perk up.

The reversal of shock occurs in the majority of my patients, but the M/M outcomes at the end are similar per studies done all over the world.

The short of it:
Sepsis>adrenally insufficient>low cortisol/steroid hormones>give stress dose> patients perk up.

Last night, I had a patient who was given 6 LITERS of 0.9NS fluid and still his blood pressure was 80/50... gave hydro and sent him to the MICU w/ a central line for pressor support (dopa/levophed).
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Thanks you so much....I had a presentation on this today because a doctor at the hospital where I am on rotation prescribed 500 mg-bolus dose of hydrocortisone for a septic shock patient who was also had adrenal insufficiency.
 
taken2 said:
Thanks you so much....I had a presentation on this today because a doctor at the hospital where I am on rotation prescribed 500 mg-bolus dose of hydrocortisone for a septic shock patient who was also had adrenal insufficiency.
Click to expand...

That seems excessive...was there adrenal insufficiency prior to the development of sepsis? Did they do an ACTH test? None of the studies I'm aware of tested more than 300mg per day, and as a prior poster mentioned, they were pretty equivocal in terms of outcomes.
 
Praziquantel86 said:
That seems excessive...was there adrenal insufficiency prior to the development of sepsis? Did they do an ACTH test? None of the studies I'm aware of tested more than 300mg per day, and as a prior poster mentioned, they were pretty equivocal in terms of outcomes.
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He was treating secondary adrenal insufficiency due to sepsis. We all thought it was excessive and the nurse practitioner covering for him that evening changed the dose back to 100 mg but the pharmacist got a call couple of hours later from the doctor putting the patient back on additional 400 mg ( +100mg already given at that point).
 
"Critical illness related corticosteroid insufficiency."

In septic shock, sympathetic overdrive to produce massive amounts of endogenous catecholamines to counteract vasodilation can lead to adrenal insufficiency and low serum cortisol. Lack of endogenous corticosteroids can lead to a reduced adrenergic response.

If you've adequately fluid resuscitated the patient and are unable to obtain adequate SVO2 > 70 % and your CVPs aren't responding to norepinephrine, the patient is generally considered adrenally insufficient. At this point, all patients should receive vasopression (VASTT [spelling] study) and corticosteroids. Studies support not using a cortisol stimulating test at this point as there is no benefit.

This is my understanding and if anyone notices any inaccuracies or feels they can improve my answer feel free to do so.
 
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