Does the Society of Critical Care Medicine (SCCM) recommend corticosteroids for surviving sepsis?

From the Guidelines

The Surviving Sepsis Campaign (SCCM) recommends corticosteroids in specific sepsis scenarios, particularly for patients with septic shock who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy, as stated in the 2016 guidelines 1. The current recommendation is to use intravenous hydrocortisone at a dose of 200 mg per day, administered either as an infusion or in divided doses, for patients with septic shock who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy. Some key points to consider when using corticosteroids in sepsis include:

• The recommended duration is typically 5-7 days with gradual tapering rather than abrupt discontinuation.
• Hydrocortisone should be considered when patients continue to require moderate to high doses of vasopressors despite appropriate fluid resuscitation.
• The physiological rationale for corticosteroid use in septic shock includes addressing relative adrenal insufficiency that may occur during severe illness, reducing inflammation, improving vascular tone, and enhancing the sensitivity of blood vessels to vasopressors.
• It's essential to note that corticosteroids are not recommended for all sepsis patients but specifically for those with refractory septic shock.
• Potential adverse effects include hyperglycemia, which should be monitored and managed during treatment, as highlighted in the guidelines 1. The guidelines emphasize that corticosteroids should not be used in adult patients with sepsis without shock, and the use of corticosteroids in other critically ill patients should be based on specific conditions and guidelines 1.

From the Research

SCCM Recommendations for Corticosteroids in Surviving Sepsis

• The Surviving Sepsis Campaign advises consideration of corticosteroids in patients with vasopressor and fluid-resistant septic shock 2.
• The use of physiologic-dose steroids can reduce vasopressor requirements and improve time of shock resolution 2.
• The 2021 Surviving Sepsis Campaign guidelines recommend corticosteroids for vasopressor and fluid-refractory septic shock patients 3, 4.
• Hydrocortisone is recommended at a dose of 100 mg intravenously every 8 hours or 50 mg intravenously every 6 hours 2.
• Alternative corticosteroids such as methylprednisolone and dexamethasone may be considered in cases of hydrocortisone shortage 4.

Guidelines and Recommendations

• The Surviving Sepsis Campaign guidelines provide recommendations on the care of hospitalized adult patients with (or at risk for) sepsis 3.
• The guidelines include new weak recommendations for use of balanced fluid over saline 0.9%, use of intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement 3.
• The recommendation for initial fluid resuscitation in septic shock of 30 mL/kg crystalloid has been downgraded from strong to weak 3.

Clinical Practice and Variability

• Significant variability exists when corticosteroids are prescribed for septic shock, with different interpretations of the guidelines 5.
• The method and timing of corticosteroid discontinuation also differed among providers 5.
• Self-described prescribing patterns from intensivists closely matched their actual behavior, suggesting variability is due to differing interpretations of the guidelines themselves 5.