Outline the evidence for the role of glucocorticoids in ARDS and septic shock and the current controversies surrounding their use in these conditions
ARDS – ARDS part of the sepsis inflammatory response, fibroprolifeartive pahse associated with laying down of collagen, hence use of steroids to reduce the extent of these processes.
Lines of evidence: a) Meduri study (JAMA) cross over trial showed a reduction in lung injury score and improved mortality (small sample). (Candidates not expected to name authors, if they do get bonus marks)
b) Recent Meduri study : Reduction in LIS, length of stay and duration of IPPV
c) Recent ARDS net study: the use of steroids was not associated with any benefit and there was an increased incidence of reintubation. Improves oxygenation faster, more ventilator and shock free days, but higher complications such as weakness, reintubation – no mortality advantage
Septic shock –
• one of the most controversial areas,
• Basis thought to be relative adrenal insufficiency (RAI)
• Basis of RAI diagnosis questionable, -doubts about validity of using plasma cortisol and the synacthen test.
• Shown to be of benefit in meningitis
• In septic shock – high dose steroids (30 mg/Kg) clearly increase mortality
• Low dose steroids improve shock reversal – only one RCT study showed improvement (ANNANE) but study limitations- trial design, use of etomidate
• A recent multicentre-study (CORTICUS) demonstrated a lack of benefit with steroids, although the study was underpowered.
This old issue is easy to scoff at from the enlightened position we now occupy, but the pendulum of expert opinion keeps swinging.
Let us consider this answer from such a position.
As far as ARDS goes, steroids have long been viewed as harmful. The discussion of pharmacological management for ARDS goes into this in greater detail.
Steroids in sepsis have also seen their heyday come and go, and now have been degraded to the position of ancillary therapies in vasopressor-refractory shock, to treat some imaginary spectre of relative cortisol deficiency. Everybody now agrees that high dose steroids increase mortality, and that though the evidence for steroids in sepsis is pretty weak, nobody should ever die of sepsis without having tasted some steroids.
To finish with this would be pretty superficial. In general, thecomplicated issue of steroids in sepsisis dealt with in some detail in a dedicated chapter on this topic, nested within the greater discussion of the management of shock. This discussion is also relevant to the topic of relative adrenal insufficiencywhich is an endocrine curiosity found in severe disease states. The question of using steroids in refractory shock states is answered in the discussion of Question 12 from the second paper of 2000.
In brief, a list of acceptable indications is as follows:
Anyway, the above is time-wasting gibberish. The college asks us to outline the evidence and current controversies. Thus:
LITFL have an excellent page, summarising the current literature on steroids in sepsis.
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