Review Question - QID 217196

This patient with poorly controlled emphysema (suggestive of chronic corticosteroid use) presents with fever, altered mental status, recent dysuria, chills, hypotension refractory to fluids, tachycardia, tachypnea, and costovertebral angle tenderness in the setting of positive blood cultures for gram-negative rods, indicative of an ascending Escherichia coli urinary tract infection that has progressed to septic shock. Given that she continues to be hypotensive despite fluid resuscitation and vasopressor treatment (norepinephrine), the most appropriate next step in management is to administer hydrocortisone.

Septic shock is defined as sepsis (at least 2 of the following: temperature >100.4°F or <96.8°F, respirations >20/min, heart rate >90/min, leukocytes >12,000 or <4,000 in the setting of likely infection) plus hypotension refractory to fluid resuscitation. Septic shock is treated with empiric broad-spectrum antibiotic therapy and hemodynamic support with intravenous fluids and vasopressors (norepinephrine preferred). If hypotension persists despite this therapy, adrenal insufficiency should be suspected and glucocorticoids should be administered empirically. Evaluation of adrenal reserve is not required due to the unreliability of cortisol measurements during infection. The mechanism of adrenal insufficiency in septic patients is poorly understood but is thought to result from impairment of the hypothalamic-pituitary-adrenal axis and glucocorticoid resistance.

Marik and Zaloga studied the incidence of adrenal insufficiency in patients with septic shock. They found that 61% of patients had a baseline cortisol concentration of <25 mcg/dL and 37% of patients were responsive to corticosteroids.

Incorrect Answers:
Answers 1 and 2: Administering additional 0.9% saline or lactated ringer solution is inappropriate because this patient has already been giving intravenous fluids with a poor hemodynamic response. This suggests that she is already euvolemic and giving additional fluids alone is not indicated.

Answer 4: Changing norepinephrine to vasopressin is inappropriate. Norepinephrine is the preferred vasopressor in septic shock. Additionally, adrenal insufficiency should be suspected in this persistently hypotensive patient, which would not be corrected with vasopressin.

Answer 5: Starting a continuous epinephrine infusion is inappropriate because adrenal insufficiency should be suspected in this persistently hypotensive patient with likely chronic steroid use and treated empirically with a corticosteroid.

Bullet Summary:
In patients with septic shock and hypotension refractory to fluid resuscitation and vasopressor administration, adrenal insufficiency should be suspected and treated empirically with hydrocortisone.