Reddy Pramod
Division of General Internal Medicine, UF Health Jacksonville, Jacksonville, FL.
Am J Ther. 2021;28(2):e238-e244. doi: 10.1097/MJT.0000000000001064.
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.
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.
住院的低血压患者通常会检测血浆皮质醇水平，并且通常会进行促肾上腺皮质激素（ACTH）激发试验以进一步检查低皮质醇血症。必须认识到，相对肾上腺皮质功能不全（AI）是患病患者皮质醇水平低和ACTH激发试验失败的最常见原因。在重症患者中，皮质醇和合成ACTH激发试验均不可靠。在临床实践中，脓毒性休克患者使用皮质类固醇治疗可立即带来血流动力学益处，减少血管升压药的使用并降低对呼吸机的依赖。
对于脓毒性休克患者相对AI的诊断标准、合适的皮质醇水平以及合成ACTH激发试验所用剂量，目前尚无共识。关于补充类固醇治疗对死亡率的益处以及辅助使用氟氢可的松存在争议。
对随机对照试验和荟萃分析进行PubMed检索。
尽管存在诸多争议，但医院医生仍经常对伴有低皮质醇血症的脓毒性休克患者使用类固醇。对于大多数相对AI患者，氢化可的松应作为类固醇的首选，对于难治性休克患者，可根据具体情况加用氟氢可的松。短期使用类固醇引起的大多数不良反应在住院环境中很容易处理。
