Steroid use in refractory septic shock — FFICM MCQ

Correct answer: E — Start intravenous hydrocortisone for vasopressor-refractory septic shock

The correct answer is E, start intravenous hydrocortisone for vasopressor-refractory septic shock. This patient has septic shock with an ongoing significant noradrenaline requirement (0.45 micrograms/kg/min) plus vasopressin despite source control, antibiotics and adequate fluid resuscitation, which is precisely the population in whom adjunctive corticosteroids reduce time to shock resolution. Current guidance recommends IV hydrocortisone 200 mg/day (50 mg IV every 6 hours or as a continuous infusion) once vasopressor doses reach a moderate-to-high threshold, irrespective of adrenal function testing. Good biventricular function on echo excludes a cardiac cause for the persistent hypotension, reinforcing that the vasopressor requirement is due to vasoplegia amenable to steroid therapy. No ACTH stimulation test or history of chronic steroid use is required before starting treatment; this is a clinical decision based on vasopressor dose and duration of shock. Why the other options are wrong: B. High-dose methylprednisolone for 6 weeks: high-dose, prolonged corticosteroid regimens were used in older, now-abandoned protocols and increase infection and hyperglycaemia risk without mortality benefit; current practice uses low-dose hydrocortisone for a short, defined course. D. Avoid steroids in septic shock routinely: steroids are not for all septic shock, but are indicated once vasopressor requirements are significant and refractory, which this patient meets. A. Use fludrocortisone alone: fludrocortisone is a pure mineralocorticoid with negligible glucocorticoid activity and is not the recommended monotherapy; when used, it is an optional adjunct to hydrocortisone, not a substitute. C. Delay steroids until ACTH stimulation testing: adrenal function testing is not required or recommended before starting hydrocortisone in septic shock, as relative adrenal insufficiency assessment does not reliably predict response and delays a time-sensitive intervention. Key point: Start low-dose IV hydrocortisone (200 mg/day) in septic shock once vasopressor requirements remain high despite adequate fluid resuscitation and source control, without waiting for ACTH testing.

Reference: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, Society of Critical Care Medicine (widely adopted in UK critical care practice), https://www.sccm.org/clinical-resources/guidelines/guidelines/surviving-sepsis-guidelines-2021