Critically evaluate the use of adjunctive corticosteroid treatment in the management of septic shock.
Long history of use
Potential mechanism of action includes:
Anti-inflammatory/anti- cytokine action Treatment of adrenal dysfunction
Vasopressor and inotrope- by beta -receptor upregulation sparing action
Cheap, simple widely available
Muscle weakness Increased infection risk Increased risk of GI bleed
Several randomised trials with conflicting results
Annane (2002) and CORTICUS (2008) used short Synacthen test to stratify patients – divergent effects on mortality reported
Recent large scale trials:
ADRENAL – no effect on mortality but more rapid reversal of shock and more rapid wean of mechanical ventilation and ICU stay
APPROCCHS – Reduction in mortality and more rapid shock reversal and ventilator wean. Used fludrocortisone in addition to hydrocortisone – role of this is unclear.
Neither trial demonstrated clinically important side effects
Although effect on mortality still uncertain the evidence suggests patients are weaned from mechanical ventilation faster and discharged from ICU earlier. Given the good safety profile this may be enough rationale for use, and likely to have substantial cost benefits as well.
ADRENAL (Venkatesh et al, 2018): no mortality difference at 90 days, unless you're in Australia and New Zealand
APROCCHSS (Annane et al, 2018): 6% mortality reduction in the steroid group, but a very low fragility index.
LITFL have an excellent page, summarising the current literature on steroids in sepsis.
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