Corticosteroid Therapy in Septic Shock

adrenal-header-image

I was reviewing my ICU notes and was wondering the roles of corticosteroid therapy for sepsis/septic shock.  Here are the current summary for corticosteroid therapy for sepsis/septic shock according to uptodate.com:

SUMMARY AND RECOMMENDATIONS

Summary

  • Laboratory assays of plasma cortisol concentration and response to adrenocorticotropic hormone (ACTH) stimulation are likely unreliable in critically ill patients. (See ‘Assessing adrenal reserve’ above.)
  • Suboptimal cortisol production during septic shock has been termed “functional” adrenal insufficiency, “relative” adrenal insufficiency, or “critical illness-related corticosteroid insufficiency (CIRCI)”. Broadly accepted consensus about diagnostic criteria for this entity is lacking. (See ‘Relative adrenal insufficiency’ above.)
  • In patients without shock, or patients with less severe septic shock (defined as those in whom fluid resuscitation and pressor therapy have restored hemodynamic stability), corticosteroid therapy does not appear to be beneficial.
  • Some studies suggest that corticosteroid therapy is most likely to be beneficial in patients who have severe septic shock (defined as a systolic blood pressure <90 mmHg for more than one hour despite adequate fluid resuscitation and vasopressor administration). Data from ongoing clinical trials are needed to confirm that benefit. (See ‘Clinical evidence’ above.)
  • The adrenocorticotropic hormone (ACTH) stimulation test has failed to consistently identify patients with septic shock that benefit from corticosteroid use. This, together with the unreliability of available plasma cortisol assays suggest that ACTH stimulation testing is not clinically useful in distinguishing responders from not responders. (See ‘Clinical evidence’ above.)

Recommendations

  • We suggest that intravenous corticosteroid therapy (200 to 300 mg per day) be administered to adult patients with severe septic shock (defined as a systolic blood pressure <90 mmHg for more than one hour despite both adequate fluid resuscitation and vasopressor administration) (Grade 2C).
  • We suggest NOT administering corticosteroid therapy to patients without shock, or patients with less severe septic shock (defined as those in whom fluid resuscitation and pressor therapy have restored hemodynamic stability) (Grade 2B).
  • Response to ACTH testing should not be used to select patients for corticosteroid therapy. (See ‘Clinical evidence’ above.)
  • We typically administer hydrocortisone (dose) for five to seven days and taper the dose as guided by the clinical response. Close observation of those patients whose steroid therapy is stopped without being tapered is warranted. We do not add fludrocortisone to our regimen. (See ‘Administration’ above.)

Snip20140926_17 Snip20140926_18

As always, thanks for reading.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s