519: EVALUATION OF CATECHOLAMINE DOSE AT HYDROCORTISONE INITIATION AS A PREDICTOR OF SHOCK-FREE SURVIVAL IN PATIENTS WITH SEPTIC SHOCK

Abstract

The Surviving Sepsis Campaign Guidelines recommend against starting hydrocortisone (HC) in patients with septic shock unless their condition responds poorly to fluids and vasopressors. However, the clinical criteria to identify patients who will respond to HC have not been well defined in the literature. This study sought to identify factors associated with response to HC in patients with septic shock.

Catecholamine dose at the time HC is initiated is an independent predictor of 7 day shock-free survival (SFS).

This retrospective chart review included adult medical intensive care patients with septic shock on catecholamines who received HC 200-300 mg/day for at least 48 hours. Patients receiving steroids within the preceding 90 days were excluded. SFS was defined as patients alive and off vasopressors at day 7. Catecholamine doses at HC initiation were converted to norepinephrine (NE)-equivalent doses, and compared between patients achieving SFS and those not achieving SFS with the Mann-Whitney U test. Additional factors available at the time of HC initiation hypothesized to influence SFS were included in a multivariate logistic regression analysis.

Eighty-eight patients were included in the study, with median APACHE II and SOFA scores of 25 and 13, respectively. At the time of HC initiation, most patients were on mechanical ventilation (81%) and vasopressin (59%), and had a median central venous pressure and mean arterial pressure of 14 mm Hg and 65 mm Hg, respectively. The median NE-equivalent dose at HC initiation was 26 mcg/min, but had a wide range (2 to 133 mcg/min). Forty-nine patients (56%) achieved SFS at day 7. There was no difference in median NE-equivalent dose between patients achieving SFS and those not achieving SFS (21 vs. 27 mcg/min, p=0.06). After correction for APACHE II, SOFA, and vasopressin use at the time of HC initiation with logistic regression, NE-equivalent dose was not independently associated with SFS (p=0.56).

The catecholamine dose at the time of HC initiation for the treatment of septic shock did not correlate with SFS. Further studies to identify clinical criteria for predicting response to HC therapy are necessary.