A patient with septic shock on noradrenaline has persistent hypotension despite adequate fluid resuscitation. Random serum cortisol is 180 nmol/L with no increment after ACTH stimulation test. The diagnosis of relative adrenal insufficiency is made, and the treatment of choice is:

• A Hydrocortisone 200 mg/day as continuous infusion or divided doses ✓
• B High-dose hydrocortisone 200 mg bolus IV
• C Prednisolone 40 mg orally once daily
• D Dexamethasone 6 mg IV once daily

Explanation

The CORTICUS and ADRENAL trials established that low-dose hydrocortisone (200 mg/day IV, given as 50 mg 6-hourly or continuous infusion) should be used for refractory septic shock with vasopressor dependence, particularly if the ACTH stimulation test suggests relative adrenal insufficiency. High-dose corticosteroids worsen outcome in septic shock. Dexamethasone lacks mineralocorticoid activity and interferes with subsequent ACTH testing.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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