What’s the Evidence? Corticosteroids in Sepsis?

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December 1, 2015 by dailybolusoflr

By: Nick Rademacher, MD

Surviving Sepsis Suggestions

  • Do not use steroids unless refractive to BOTH fluids and vasopressor therapy.
    • Vasopressor trial is 60 minutes of nonresponsivness
  • If needed give pulse of 200mg IV hydrocortisone


Rationale Summary

  • This recommendation is based on several contradictory studies
  • RCT of patients in vasopressor-unresponsive septic shock with significant shock reversal and reduction in mortality.2
    • Reproduced in 2 smaller RTCs 3,4
  • Large multicenter trial with patients not in sustained shock did not show mortality benefit with steroids 5
    • Everyone got steroids, regardless of response to pressors.

Low Dose Steroids

  • Results varied based on studies included in systemic reviews. 
    • With only high quality studies it does not appear low dose steroids offer statistically significantly difference.

References

  1. Surviving Sepsis Campaign International Guidelines for Management of Severe Sepsis and Septic Shock: 2012, condensed from Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Intensive Care Med 2013; 39(2): 165-228 and Crit Care Med 2013; 41(2): 580-637.
  2. Annane D, Sébille V, Charpentier C, et al: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288:862–871
  3. Briegel J, Forst H, Haller M, et al: Stress doses of hydrocortisone reverse hyperdynamic septic shock: A prospective, randomized, double-blind, single-center study. Crit Care Med 1999; 27:723–732, 177. 
  4. Bollaert PE, Charpentier C, Levy B, et al: Reversal of late septic shock with upraphysiologic doses of hydrocortisone. Crit Care Med 1998; 26:645–650
  5. Sprung CL, Annane D, Keh D, et al; CORTICUS Study Group: Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008; 358:111–124

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