A 70-year-old man with a history of hypertension and type 2 diabetes presents to the emergency department from home with fever, cough, and shortness of breath for two days. He is a nonsmoker and was immunized against influenza in the fall. Vitals at triage are temperature 102.7°F, blood pressure 105/61 mmHg, heart rate 118 bpm, respiratory rate 22 bpm, and oxygen saturation 89% on room air. The chest X-ray confirms pneumonia. The nurses have already established two intravenous (IV) lines of normal saline and provided supplemental oxygen via nasal cannula that corrects his hypoxia. He is also receiving appropriate antibiotics. His blood pressure begins to drop but responds to IV fluids. You wonder if IV hydrocortisone would provide any additional benefit.
The Surviving Sepsis Campaign recently published its 2016 guidelines. It continues to give a weak recommendation for the use of intravenous hydrocortisone at a dose of 200 mg per day in patients with refractory septic shock (ie, inadequate response to fluid resuscitation and vasopressor therapy); this is based on low-quality evidence. As stated by the campaign:
We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day (weak recommendation, low quality of evidence).