List your indication for the use of corticosteroids in the management of refractory shock.

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College Answer

Candidates should demonstrate a good understanding of the background and current interest  in this area. The use of corticosteroids during refractory shock is undergoing a resurgence of interest following the publication of a number of interesting papers. A large RCT  assessing the use of high doses of steroids (eg. dexamethasone (Shock Pack 120mg] or methylprednisolone [2g]} in septic shock was associated  with no overall benefit, and indeed a higher mortality  in the subgroup with renal impairment. More recently, interest has developed  in the use of more  physiologic  doses of corticosteroids  (eg  120 to  240 mg  of  hydrocortisone)  to  treat a presumed  inadequate  intrinsic cortisol response in the presence of refractory shock. The aetiology of the cortisol deficiency could be due to adrenal, pituitary or hypothalamic.

Typical indications for physiologic doses (bolus or infusion) could include:
•  known previous steroid dependence,
•  recent steroid administration  (eg. course for > 1 week in last 6 months),
•  shock associated with coagulopathy (adrenal or pituitary haemorrhage more likely),
•  prolonged inotrope/vasopressor dependency (> a few days).
•  use of very high doses of inotropes/vasopressors to maintain acceptable goals.

Discussion

This question vaguely resembles Question 22 from the first paper of 2008: "Outline the evidence for the role of glucocorticoids  in ARDS and septic shock and the current controversies surrounding their use in these conditions". On a more sepsis-specific note, Question 16 from the first paper of 2013 asks "Discuss the potential role of corticosteroid administration as adjunctive treatment for septic shock" .

The issue of steroids in sepsis is treated with greater detail in another chapter.

One could evolve this answer into a critical evaluation of the use of steroids in refractory shock. The following is brief summary of their theorical benefits:

Theoretical benefits of steroids in shock

  • Reversal of relative adrenal insufficiency
  • Reversal of inflammatory overactivity
  • Reprogramming of the immune response
  • Improved responsiveness of α-1 receptors (thus, decreased catecholamine requirements)
  • Correction of vasoplegia by deactivation of nitric oxide synthase
  • Improved cardiac tolerance of bacterial endotoxin
  • Improved retention of resuscitation fluid

However, the college only asks you to list your indications. The candidate is not invited to prattle on about nitric oxide synthase.

Thus, a current list of indications would resemble the following:

  • Adrenal insufficiency
    • Due to primary hypoadrenalism
    • Due to withdrawal of chronic exogenous corticosteroids
    • Due to relative insufficiency during critical illness
  • Severe septic shock
    • If the shock state is refractory to vasopressors and fluid resuscitation
  • Shock states due to autoimmune inflammatory disease
    • Severe vasculitis with widespread SIRS
    • Severe autoimmune myocarditis with cardiogenic shock

References

References

Byhahn, C., V. Lischke, and K. Westphal. "Translaryngeal tracheostomy in highly unstable patients." Anaesthesia 55.7 (2000): 678-683.

 

Ambesh, Sushil P., et al. "Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia Blue Rhino versus Griggs’ guidewire dilating forceps." Anesthesia & Analgesia 95.6 (2002): 1739-1745.

 

Antonelli, Massimo, et al. "Percutaneous translaryngeal versus surgical tracheostomy: A randomized trial with 1-yr double-blind follow-up*." Critical care medicine 33.5 (2005): 1015-1020.