Impact of bolus application of low-dose hydrocortisone on glycemic control in septic shock patients.

摘要

OBJECTIVE: To determine whether glycemic control is less feasible when hydrocortisone is given as a bolus compared with continuous application in septic shock patients. DESIGN: Observational prospective pilot study. SETTING: Fourteen-bed surgical university hospital ICU. PATIENTS: Sixteen consecutive patients with septic shock receiving a continuous infusion of 200[Symbol: see text]mg hydrocortisone/day and an infusion regime of insulin keeping blood glucose below 150[Symbol: see text]mg/dl. INTERVENTION: Blood glucose and insulin infusion were adjusted to steady state before intervention. At baseline, the continuous hydrocortisone infusion was replaced with a single bolus of 50[Symbol: see text]mg hydrocortisone. During a subsequent 6-h period, blood glucose was monitored hourly and insulin infusion was kept constant. Afterwards, hydrocortisone application and adjustment of blood glucose was resumed according to standard treatment. RESULTS: Mean blood glucose in steady state at baseline immediately prior to intervention was 128[Symbol: see text]mg/dl (range 114-141[Symbol: see text]mg/dl; 95% confidence interval). After bolus injection of hydrocortisone, blood glucose increased significantly within 6[Symbol: see text]h with peak levels of 154[Symbol: see text]mg/dl (range 132-178[Symbol: see text]mg/dl; p[Symbol: see text]<[Symbol: see text]0.01). Blood glucose returned to baseline with restoration of continuous hydrocortisone infusion. There were marked inter-individual variations with peak glucose values up to 254[Symbol: see text]mg/dl, but no significant difference in intra-individual glucose variability before and after bolus injection of hydrocortisone. CONCLUSIONS: Bolus injections of hydrocortisone may induce significant increases of blood glucose in patients with septic shock. The individual response is highly variable and we speculate that repetitive boluses would induce marked undulation of blood glucose. In terms of glycemic-control strategies, a continuous infusion of hydrocortisone seems to be preferable.