Plasma cortisol is commonly obtained in hospitalized hypotensive patients, and adrenocorticotropic hormone (ACTH) challenge is typically conducted to further workup hypocortisolemia. It is important to recognize that relative adrenal insufficiency
(AI) is the most common cause of low cortisol levels and failed ACTH challenge in ill patients. Both cortisol and synthetic ACTH challenge assays are unreliable in critically ill patients. In clinical practice, corticosteroid therapy in septic shock patients results in immediate hemodynamic benefits with less vasopressor and ventilator dependence.
Areas of Uncertainty:
There is no consensus about the diagnostic criteria of relative AI
, appropriate cortisol level, and the dose used for synthetic ACTH challenge in patients with septic shock. There is controversy about the mortality benefits of supplemental steroid therapy and about the use of adjunctive fludrocortisone.
PubMed search of randomized control trials and meta-analyses.
Despite all the controversies, hospital physicians frequently use steroids in patients with septic shock with hypocortisolemia. Hydrocortisone should be the choice of steroid for most relative AI
patients, and fludrocortisone can be added on a case-by-case basis in refractory shock. Most of the adverse effects induced by a short course of steroids are easily managed in the inpatient setting.