IS:
This is not a case presentation, but want to take a poll on what people are doing about steroids and sepsis. Do you administer steroids emperically after initial fluid bolus or do you attempt resuscitation per the 6hr bundle first and then administer steroids if still on pressors or hypotensive?
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I personally give hydrocortisone if the patient is hypotensive despite fluid replacement and is pressor dependent, after the 6 hour bundle.
I also wait at least for the 6-hour bundle. I sometimes will also order an AM cortisol (with its known inconsistencies and all) looking for very high or low values.
Do you bother with the stim test or just empirically give steroid to the pressor-dependent septic patient?
This is still a highly controversial issue after two contradicting meta-analyses.
A large ongoing European Study (CORTICUS) is supposed to address this question.
Meanwhile there is no established standard of care despite “Severe Sepsis Bundles” by IHI pushes for steroids.
Unless they are on chronic steroids, I prefer to do a cort stim during the initial resucitation, and base the decision on their initial response to resucitation and whether they are a non-responder to the cort stim.
Despite the ongoing study, I suspect that a lot of this data will need to be readressed when we get better at measuring "free" cortisol levels!
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