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We thank Dr Tibby,1 admire his work, and believe that his findings have saved the lives of many children with septic shock. We wish to be more clear on two opinions presented in our review. First, we do not recommend hydrocortisone therapy for relative adrenal insufficiency (basal cortisol >18 mg/dl but ACTH response increment <9 mg/dl), we only recommend further study. Second, we do recommend hydrocortisone for patients with dopamine resistant shock and classical adrenal insufficiency (central HPA axis failure = basal cortisol level <5 mg/dl, peripheral adrenal failure = peak level after ACTH <18 mg/dl). As to hydrocortisone dosage, the classical literature has cited a treatment range between 2 and 50 mg/kg/day. This low end dosage achieves cortisol levels seen in healthy patients undergoing routine surgical procedures, and the high end dosage attains circulating levels similar to those reported in septic shock survivors with the highest cortisol levels. We recommend titrating dosage according to patient haemodynamic response. For clinicians without ready access to cortisol levels, we recommend treatment based on the presence of risk factors. For example, purpura fulminans is a risk factor for adrenal failure, whereas chronic prior steroid exposure is a risk factor for hypothalamic–pituitary–adrenal axis failure.
Competing interests: None declared.