Pharmacology

Hydrocortisone

Hydrocortisone (Solu-Cortef) is a pharmacologic analog of the steroid hormone cortisol (identical structure) that serves as a reference to gauge the relative mineralcorticoid and glucocorticoid potencies of other steroids. This is similar to how morphine equivalents are used to gauge the analgesic potencies of other opioids.

As an anesthesiologist, I see a fair number of patients on low-dose steroid supplementation (most often as prednisone) coming in for various surgeries. The concern with being on long-term steroids is relative adrenal gland suppression that may not respond appropriately when confronted with the overwhelming stress of surgery. I don’t routinely administer “stress dose” steroids for patients taking 5 mg of daily prednisone, but will certainly consider hydrocortisone for patients on a chronic, high dose steroid regimen coming in for large operations.

As an intensivist, steroids seem to be the last resort for SO MANY clinical situations, and it’s a point of contention among ICU doctors. Based on the evidence, steroids do not have a role in traumatic brain injury (TBI) or the later stages of acute respiratory distress syndrome (ARDS). Most commonly, I administer steroids for COPD/asthma exacerbations, vasogenic edema associated with intracranial tumors, Pneumocystis pneumonia, vasculitides, and as part of the immunosuppression regimen for patients with new organ transplants.

The role for hydrocortisone in refractory shock was a point of contention for many years, but the results of the recent ADRENAL study shows that steroids confer no difference in mortality in patients on pressors and mechanical ventilation with septic shock when compared to placebo. Additionally, steroids may actually increase the risk of metabolic derangements like hyperglycemia and encephalopathy.

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Rishi

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