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In Reply: Dr Brown asks whether the observed reduction in mortality was related to the inclusion of a large number of patients with absolute adrenal insufficiency. Among nonresponders, the percentage of patients with absolute adrenal insufficiency (ie, cortisol levels before and after corticotropin stimulation <18 µg/dL)¹ was 45%. Removing such patients from the analysis of nonresponders increases the difference between placebo and corticosteroid groups from 10% to 17%.

In response to Drs Schenarts and March, 72 patients received etomidate within the 12 hours preceding inclusion prior to the July 1997 protocol amendment. Undoubtedly, etomidate contributed to adrenal insufficiency since there were 68 nonresponders in this subgroup. However, our study aimed at demonstrating that low doses of corticosteroids can improve survival among patients with septic shock with adrenal insufficiency, regardless of its mechanism. Thus, there was no reason to exclude these patients from the analysis. In practice, we suggest avoiding the . . . [Full Text of this Article]

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