BCCCP: Relative Adrenal Insufficiency and Stress-Dose Steroid Therapy Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old man with septic shock remains hypotensive on high-dose norepinephrine despite adequate fluid resuscitation. Empiric low-dose hydrocortisone is being considered for possible Critical Illness-Related Corticosteroid Insufficiency (CIRCI). Which statement best describes the utility of routine laboratory markers for diagnosing CIRCI in this setting?

Classic electrolyte findings of hyponatremia and hyperkalemia are unreliable for diagnosing CIRCI in septic shock.
A random cortisol concentration below 10 µg/dL definitively establishes CIRCI.
An inadequate cortisol increment (<9 µg/dL) after ACTH stimulation is the gold standard for diagnosing CIRCI in ICU patients.
An elevated eosinophil count reliably indicates CIRCI in critically ill patients.

Question 2 of 10

2. Question

A 62-year-old man with type 2 diabetes and hypertension is admitted to the MICU with septic shock due to pneumonia. On hospital day 2, despite receiving 30 mL/kg of IV fluids, broad-spectrum antibiotics, and ongoing source control, he remains hypotensive on a norepinephrine infusion at 0.2 mcg/kg/min. His vital signs are: T 38.5 °C, HR 110 bpm, BP 78/52 mm Hg (MAP 61 mm Hg), RR 22 breaths/min, SpO₂ 96% on FiO₂ 0.5. Laboratory studies drawn one hour after the hypotensive episode show: sodium 148 mEq/L (135–145), potassium 3.2 mEq/L (3.5–5.0), glucose 210 mg/dL (70–140), and random total cortisol 18 mcg/dL (normal 10–20). There is no recent steroid exposure. Considering current Surviving Sepsis Campaign 2021 guidelines and the clinical context, which of the following statements best describes the appropriate diagnostic approach to suspected critical illness-related corticosteroid insufficiency (CIRCI) in this patient?

Refractory hypotension despite adequate fluid resuscitation and high-dose vasopressors is the primary indication for empiric corticosteroids; classic electrolyte and glucose abnormalities are unreliable in CIRCI.
Hypokalemia and hypernatremia in septic shock are hallmark findings of CIRCI and should prompt immediate high-dose steroid therapy.
A random cortisol level ≥ 18 mcg/dL definitively excludes CIRCI, so cosyntropin stimulation testing must be done before considering steroids.
Stress hyperglycemia indicates sufficient adrenal function in critical illness and excludes the need for further endocrine evaluation.

Question 3 of 10

3. Question

A 65-year-old man is admitted to the intensive care unit following severe trauma. He is on mechanical ventilation and requires increasing doses of norepinephrine to maintain a mean arterial pressure above 65 mmHg despite aggressive fluid resuscitation. His vital signs are BP 85/50 mmHg, HR 115 bpm, and temperature 38.5°C. Initial labs show Na 148 mEq/L, K 3.2 mEq/L, and glucose 180 mg/dL. Considering critical illness-related corticosteroid insufficiency (CIRCI), which of the following statements BEST evaluates the diagnostic utility of the patient’s electrolyte and glucose abnormalities for confirming CIRCI?

The observed hypernatremia, hypokalemia, and hyperglycemia strongly support a diagnosis of CIRCI in this critically ill patient.
The absence of hyponatremia, hyperkalemia, and hypoglycemia effectively excludes CIRCI in this patient.
These electrolyte and glucose abnormalities are nonspecific in critical illness and cannot reliably confirm or exclude CIRCI.
Correlating these electrolyte and glucose changes with a low random cortisol level provides definitive confirmation of CIRCI without further testing.

Question 4 of 10

4. Question

A 62-year-old man is admitted to the ICU with severe sepsis secondary to community-acquired pneumonia. He is intubated, mechanically ventilated, and has a central venous catheter in place. Despite receiving 6 L of balanced crystalloid and escalating vasopressors—norepinephrine 0.2 mcg/kg/min and vasopressin 0.04 units/min—his mean arterial pressure remains < 65 mmHg. His most recent labs show Na 138 mEq/L, K 4.1 mEq/L, glucose 180 mg/dL, and a random total serum cortisol of 32 mcg/dL (reference range 5–25 mcg/dL). The team is concerned about critical illness–related corticosteroid insufficiency (CIRCI). Which of the following findings is the most compelling indication to start empiric stress-dose corticosteroids in this patient?

Persistent hypotension (MAP < 65 mmHg) despite adequate fluid resuscitation and vasopressor support (e.g., norepinephrine ≥ 0.25 mcg/kg/min)
Hyponatremia (Na < 135 mEq/L) and hyperkalemia (K > 5.0 mEq/L)
Elevated random total serum cortisol level (32 mcg/dL)
Insufficient cortisol rise (< 9 mcg/dL) after a 250 µg cosyntropin stimulation test

Question 5 of 10

5. Question

A 62-year-old man is admitted to the ICU with severe septic shock secondary to pneumonia. He remains hypotensive (MAP <65 mm Hg) despite aggressive fluid resuscitation, norepinephrine at 0.2 μg/kg/min, and vasopressin. According to the 2021 Surviving Sepsis Campaign guidelines, what is the most appropriate next step in corticosteroid management?

Start IV hydrocortisone 200 mg per day (e.g., continuous infusion or divided doses) without performing an ACTH stimulation test
Obtain a random serum cortisol and perform a cosyntropin stimulation test before deciding on corticosteroids
Withhold corticosteroids because adrenal function testing has shown an inadequate cortisol response to cosyntropin
Administer a single high-dose dexamethasone bolus to treat refractory shock

Question 6 of 10

6. Question

According to the Surviving Sepsis Campaign 2021 guidelines, which of the following is the most appropriate indication for initiating low-dose hydrocortisone therapy in a patient with septic shock?

Random serum cortisol concentration below 10 µg/dL
Persistent hypotension requiring vasopressor support despite adequate fluid resuscitation
Imaging evidence of bilateral adrenal hemorrhage
New-onset eosinophilia (>5% of leukocytes)

Question 7 of 10

7. Question

A 62-year-old, 75-kg man is in the intensive care unit with septic shock secondary to pneumonia. He is mechanically ventilated with an FiO₂ of 0.8 and receiving norepinephrine at 0.2 mcg/kg/min via a central venous catheter. Despite aggressive fluid resuscitation and escalating vasopressor doses over the past 12 hours, his mean arterial pressure remains in the low 60s mm Hg with persistent lactic acidosis. Which of the following intravenous corticosteroid regimens is most appropriate for this patient?

Hydrocortisone 200 mg IV per day as a continuous infusion
Dexamethasone 6 mg IV once daily
Methylprednisolone 40 mg IV every 8 hours
Hydrocortisone 25 mg IV every 8 hours

Question 8 of 10

8. Question

A 62-year-old, 70-kg man is in the intensive care unit for septic shock secondary to pneumonia. Despite receiving 4 liters of intravenous fluids, his mean arterial pressure remains below 65 mmHg while on norepinephrine 0.2 mcg/kg/min and vasopressin 0.04 units/min. A random serum cortisol level is 12 mcg/dL (reference range 5–25 mcg/dL). Which of the following is the most appropriate initial hydrocortisone regimen?

Hydrocortisone 100 mg IV every 8 hours
Hydrocortisone 25 mg IV every 12 hours
Hydrocortisone 50 mg IV every 6 hours
Hydrocortisone 100 mg IV once daily

Question 9 of 10

9. Question

A 65-year-old man is admitted to the intensive care unit with severe septic shock. He is intubated on assist-control ventilation and is receiving norepinephrine at 0.5 µg/kg/min and vasopressin at 0.04 units/min to maintain a mean arterial pressure ≥ 65 mmHg despite aggressive fluid resuscitation. His history is notable for hypertension and type 2 diabetes. Which of the following corticosteroid regimens is most appropriate for this patient?

Hydrocortisone 50 mg IV every 8 hours
Hydrocortisone 50 mg IV every 6 hours
Dexamethasone 6 mg IV once daily
Methylprednisolone 40 mg IV every 12 hours

Question 10 of 10

10. Question

A 68-year-old man (weight 75 kg) is admitted to the ICU with severe septic shock due to pneumonia. After 6 hours of aggressive fluid resuscitation (30 mL/kg crystalloids), he remains hypotensive and requires norepinephrine at 0.3 mcg/kg/min and vasopressin at 0.04 units/min via a central line to maintain a mean arterial pressure > 65 mm Hg. Laboratory results show Na 148 mEq/L, K 3.2 mEq/L, and glucose 185 mg/dL. A random serum cortisol level returns at 28 mcg/dL. Given his persistent vasopressor dependence, relative adrenal insufficiency is suspected. Which of the following is the most appropriate immediate action?

Initiate empiric intravenous hydrocortisone (200 mg/day) to improve vasopressor responsiveness.
Defer hydrocortisone because the random cortisol level is above 25 mcg/dL.
Wait for classic electrolyte changes (hyponatremia or hyperkalemia) before starting steroids.
Perform a cosyntropin stimulation test to confirm adrenal insufficiency prior to steroid administration.