Discuss the potential role of corticosteroid administration as adjunctive treatment for septic shock.
Controversial unresolved topic, conflicting evidence.
In septic shock, cytokines may suppress the cortisol response to adrenocorticotropin hormone and in almost half of the patients this causes poor adrenal activity. Tissues possibly become resistant to corticosteroids because of fewer corticosteroid receptors or receptors with lower affinity.
Concept of CIRCI unclear and use of short Synacthen test to determine who may benefit from steroids is controversial
Surviving Sepsis Campaign Guidelines 2012 reoommend 200mg hydrocortisone /24hr for septic shock only if fluid resuscitation and vasopressor therapy have been inadequate to restore haemodynamic stability (grade 2C). Further recommendations are not to use the short Synacthen test, to taper hydrocortisone when vasopressors are no longer required and not to use steroids in sepsis without shock
Clear role for steroids in patients who are overtly hypoadrenal (as opposed to CIRCI) and Waterhouse-Friderichsen Syndrome
Steroid treatment is recommended as early adjunctive treatment in bacterial meningitis but studies evaluating role of steroids in bacterial meningitis with septic shock are lacking and recommendations advise treatment as per septic shock
Consider additional supplementation in patients already on steroid therapy
The use of low-dose corticosteroids in septic shock significantly reduces shock duration. No improvement in mortality has been shown except for a possible reduction in 28-day mortality in the subgroup of patients who received a prolonged course (defined as more than 5 days) of low-dose corticosteroids.
Possible adverse effects include: impaired glucose control, increased fungal infection, myopathy and poor wound healing.
Studies using low-dose corticosteroids have not shown an increase in the risk of gastrointestinal bleeding, superinfection, or acquired neuromuscular weakness compared with placebo, but may not have been adequately powered to observe significant differences in side effects.
The use of corticosteroids may affect glucose metabolism and the need for insulin administration.
Steroids in shock generally are asked about in Question 12 from the second paper of 2000.
Evidence for steroids in sepsis, and controversies surrounding their use, are asked about in 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".
Annane, Djillali, et al. "Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review." Jama 301.22 (2009): 2362-2375.
Sligl, Wendy I., et al. "Safety and efficacy of corticosteroids for the treatment of septic shock: A systematic review and meta-analysis." Clinical infectious diseases 49.1 (2009): 93-101.
Annane, Djillali. "Corticosteroids for severe sepsis: an evidence-based guide for physicians." Annals of intensive care 1.1 (2011): 1-7.
Sprung, Charles L., et al. "Hydrocortisone therapy for patients with septic shock." New England Journal of Medicine 358.2 (2008): 111.
Vassiliadi, Dimitra A., et al. "Longitudinal assessment of adrenocortical responses to low-dose ACTH in critically ill septic patients." Endocrine Abstracts (2013) 32 P26
Annane, Djillali, et al. "Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock." Jama 288.7 (2002): 862-871.