What are the guidelines for using glucocorticosteroids (steroids) in the Emergency Department (ED) for patients with sepsis, specifically when to administer and when to withhold them?

From the Guidelines

Glucocorticosteroids should be administered in the Emergency Department to septic patients who remain hypotensive despite adequate fluid resuscitation and vasopressor support (septic shock), with a recommended regimen of intravenous hydrocortisone 200 mg/day, as suggested by the Surviving Sepsis Campaign guidelines 1. The use of glucocorticosteroids in septic patients is a topic of ongoing debate, but the most recent and highest quality evidence suggests that they should be used in patients with septic shock who are not responding to conventional therapy.

Key Points to Consider

• The Surviving Sepsis Campaign guidelines suggest that intravenous hydrocortisone should not be used to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability 1.
• However, if this is not achievable, the guidelines suggest IV hydrocortisone alone at a dose of 200 mg/day 1.
• The guidelines also recommend against using the adrenocorticotropic hormone stimulation test to identify adults with septic shock who should receive hydrocortisone 1.
• In treated patients, hydrocortisone should be tapered when vasopressors are no longer required 1.
• Corticosteroids should not be administered for the treatment of sepsis in the absence of shock 1.

Recommended Regimen

• The recommended regimen is intravenous hydrocortisone 200 mg/day, either as a continuous infusion or divided into 3-4 doses.
• The duration of treatment should be individualized, but the guidelines suggest using a long course and low dose (e.g., IV hydrocortisone <400 mg/day for at ≥3 days at full dose) rather than high dose and short course in adult patients with septic shock 2.

Contraindications

• Steroids should be withheld in patients with sepsis who do not have shock or who respond adequately to fluids and vasopressors.
• They should also be avoided in patients with certain contraindications such as active gastrointestinal bleeding, severe immunosuppression, or known hypersensitivity to corticosteroids. The physiological basis for steroid use in septic shock is that critical illness can cause relative adrenal insufficiency and glucocorticoid receptor resistance, leading to inadequate cortisol activity. Steroids help restore vascular tone, increase sensitivity to catecholamines, and modulate the inflammatory response. However, they carry risks including hyperglycemia, secondary infections, and gastrointestinal bleeding, which is why their use should be restricted to patients with septic shock not responding to conventional therapy rather than all sepsis patients, as suggested by the Society of Critical Care Medicine and European Society of Intensive Care Medicine guidelines 3.

From the FDA Drug Label

In general, high dose corticosteroid therapy should be continued only until the patient's condition has stabilized, usually not beyond 48 to 72 hours. The initial dose of SOLU-CORTEF Sterile Powder is 100 mg to 500 mg, depending on the specific disease entity being treated However, in certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages.

The guidelines for using glucocorticosteroids in the Emergency Department (ED) for patients with sepsis are not explicitly stated in the provided drug label. However, based on the information provided, high-dose corticosteroid therapy should be continued only until the patient's condition has stabilized, usually not beyond 48 to 72 hours. The initial dose of hydrocortisone can range from 100 mg to 500 mg, depending on the specific disease entity being treated. In overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified 4.

• Indications for use: + Overwhelming, acute, life-threatening situations + Specific disease entity being treated
• Dosage: + Initial dose: 100 mg to 500 mg + Duration: until the patient's condition has stabilized, usually not beyond 48 to 72 hours
• Precautions: + Dosage requirements are variable and must be individualized + Dosage adjustments may be necessary due to changes in clinical status or patient exposure to stressful situations

From the Research

Guidelines for Glucocorticosteroid Use in Sepsis

The use of glucocorticosteroids in patients with sepsis is a topic of ongoing debate. The following guidelines are based on current evidence:

• Glucocorticosteroids should be considered in patients with vasopressor-dependent septic shock 5, 6, 7.
• Low-dose hydrocortisone (200-300 mg per day) is recommended for patients with septic shock and relative adrenal insufficiency 5, 6, 8.
• The diagnosis of relative adrenal insufficiency (RAI) is highly dependent on cut-off values and definition of RAI, and it is not clear yet which patients benefit most from low-dose hydrocortisone 5.
• Fludrocortisone may be considered in addition to hydrocortisone, but its role is uncertain 6, 8, 7.
• High-dose corticosteroid therapy is associated with increased harm and is not recommended 7.

Indications for Glucocorticosteroid Use

The following are indications for glucocorticosteroid use in sepsis:

• Vasopressor-dependent septic shock 5, 6, 7.
• Relative adrenal insufficiency (RAI) 5, 6, 8.
• Severe sepsis with hypotension poorly responsive to vasopressor despite adequate fluid resuscitation 9.

Contraindications for Glucocorticosteroid Use

There are no clear contraindications for glucocorticosteroid use in sepsis, but the following should be considered:

• No benefit in patients with septic shock who are not vasopressor-dependent 7.
• Potential for increased harm with high-dose corticosteroid therapy 7.
• Risk of superinfection, although this is not suggested by the majority of studies 7.