Hydrocortisone Versus Hydrocortisone Plus Fludrocortisone for the Treatment of Adrenal Insufficiency in Severe Sepsis
Hydrocortisone Versus Hydrocortisone Plus Fludrocortisone for the Treatment of Adrenal Insufficiency in Severe Sepsis
The purpose of this study is to determine if the combination of hydrocortisone plus
 fludrocortisone is more efficacious than hydrocortisone alone in treating adrenal
 insufficiency in severe sepsis.
Sepsis is a significant cause of morbidity and mortality in critically ill patients in the
 United States. As evidenced by its increasing prevalence and high mortality rates, sepsis is
 a complex and difficult syndrome to treat. Current therapeutic management of sepsis includes
 fluid resuscitation, vasopressor and inotropic support, maintenance of oxygen delivery,
 drotrecogin alpha, and steroid replacement therapy in patients who are found to have adrenal
 insufficiency. Studies in septic patients suggest that the administration of stress doses of
 hydrocortisone alone, or the combination of hydrocortisone plus fludrocortisone promotes an
 improvement in cardiovascular performance and a quicker resolution of shock symptoms. Current
 therapeutic guidelines for the treatment of severe sepsis recommend either hydrocortisone
 alone or combination therapy with hydrocortisone and fludrocortisone as therapeutic options
 for the treatment of adrenal dysfunction in severe sepsis. This study will help determine
 which regimen is more efficacious in this patient population.
Inclusion Criteria:

 -  Males and non-pregnant females > 18 years of age

 -  Patients admitted and/or pending admission to the intensive care unit

 -  Positive corticotropin stimulation test (Basal cortisol level of ≤ 34 μg/dL with Δ ≤ 9
 μg/dL after administration of 250 mg of cosyntropin)

 Patient satisfies criteria for severe sepsis Infection - one or more of the following
 criteria

 -  Documented or Suspected - positive culture results (from blood, sputum, urine, etc.)

 -  Anti-Infective Therapy - patient is receiving antibiotic, antifungal, or other
 anti-infective therapy

 -  Pneumonia - documentation of pneumonia (x-ray, etc.)

 -  WBCs - WBCs found in normally sterile .uid (urine, CSF, etc.)

 -  Perforated Viscus - perforation of hollow organ (bowel)

 SIRS - two or more of the following

 -  Temperature > 38° or < 36°

 -  Heart rate > 90 bpm

 -  Respiratory rate above 20 breaths per minute

 -  WBC > 14,000/mm3 , < 4000/mm3, or >10% Bands

 Acute organ dysfunction - one or more of the following

 -  Cardiovascular - SBP < 90 mmHg or MAP < 70 mmHg despite 20 mL/kg of fluid
 resuscitation

 -  Respiratory - PaO2/FiO2 ratio < 250, PEEP > 7.5, or require mechanical ventilation

 -  Renal - low urine output (eg, <0.5 mL/kg/hr for 1 hour despite 20mL/kg of fluid
 resuscitation, increased creatinine (>50% increase from baseline) or require acute
 dialysis

 -  Hematologic - low platelet count (< 100,000/mm3) or PT/PTT > upper limit of normal

 -  Metabolic - low pH with high lactate (eg, pH < 7.30 and plasma lactate > upper limit
 of normal

 -  Hepatic - liver enzymes > 2x upper limit of normal

 -  CNS - altered consciousness or reduced Glasgow Coma Score

 Exclusion Criteria:

 -  Patients who respond to the short cosyntropin stimulation test(Δ > 9mg/dL)

 -  Pregnancy or breast-feeding mother

 -  Evidence of acute myocardial infarction, meningitis, pulmonary embolism

 -  AIDS (CD4 < 200 cells/mL)

 -  Contraindications for corticosteroids

 -  Formal indication for corticosteroids (specifically including patients with known
 adrenal insufficiency)

 -  Onset of shock > 24 hours

 -  Etomidate administration within the 6 hours preceding randomization

 -  Cardiac arrest prior to randomization.