When are corticosteroids indicated in septic (systemic inflammatory response syndrome due to infection) shock?

From the Guidelines

Corticosteroids are indicated in septic shock when patients remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy, with the recommended regimen being intravenous hydrocortisone at a dose of 200 mg per day. This recommendation is based on the latest guidelines from the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, which suggests using IV hydrocortisone at a dose of 200 mg per day in patients with septic shock that is not responsive to fluid and vasopressor therapy 1.

Key Considerations

• The use of corticosteroids in septic shock should be considered when patients are not responding to fluid resuscitation and vasopressor therapy, as indicated by the need for escalating doses of vasopressors to maintain adequate blood pressure.
• The recommended dose of hydrocortisone is 200 mg per day, which can be administered as a continuous infusion or in divided doses.
• Treatment with corticosteroids should be initiated within the first 6-12 hours of shock onset for optimal benefit, as suggested by the guidelines 1.
• Potential adverse effects of corticosteroids include hyperglycemia, increased risk of secondary infections, and impaired wound healing, which should be monitored and managed accordingly.

Rationale

The rationale for using corticosteroids in septic shock is based on their ability to enhance vascular responsiveness to catecholamines, reduce inflammation, and stabilize cell membranes. The latest Cochrane systematic review of the use of low-dose hydrocortisone for treating septic shock showed that corticosteroids significantly reduced the risk of death at 28 days compared with placebo 1. However, the quality of evidence is generally considered low, and the decision to use corticosteroids should be made on a case-by-case basis, taking into account the individual patient's response to treatment and potential risks and benefits.

Monitoring and Discontinuation

Patients receiving corticosteroids for septic shock should be closely monitored for potential adverse effects, including hyperglycemia, which requires regular blood glucose monitoring. Steroids should be discontinued once vasopressors are no longer needed and the patient is hemodynamically stable, as suggested by the guidelines 1.

From the Research

Indications for Corticosteroids in Septic Shock

Corticosteroids are indicated in septic shock, particularly in patients with relative adrenal insufficiency (RAI) or those who are vasopressor-dependent 2, 3, 4, 5, 6. The use of low-dose corticosteroids, such as hydrocortisone, has been shown to improve shock reversal, reduce inflammation, and improve outcome in these patients.

Patient Selection

The selection of patients who may benefit from corticosteroid therapy is crucial. Patients with septic shock and RAI, as well as those with vasopressor-resistant septic shock, may benefit from corticosteroid therapy 3, 4, 5, 6. The diagnosis of RAI is often made using a corticotropin test, although the cut-off values and definition of RAI are not well established 2.

Dosage and Duration

The dosage and duration of corticosteroid therapy in septic shock are not well established. However, low-dose hydrocortisone (200-300 mg per day) for 5-7 days or longer has been shown to be beneficial in several studies 2, 3, 5. The addition of fludrocortisone may also be considered in some cases, although its role is uncertain 3, 5, 6.

Benefits and Risks

The benefits of corticosteroid therapy in septic shock include improved shock reversal, reduced inflammation, and improved outcome 2, 3, 4, 5, 6. However, the risks of corticosteroid therapy, such as superinfection, must also be considered 4. The majority of studies suggest that the risk of superinfection is not increased with corticosteroid therapy.

Key Points

• Corticosteroids are indicated in septic shock, particularly in patients with RAI or those who are vasopressor-dependent.
• Low-dose hydrocortisone (200-300 mg per day) for 5-7 days or longer may be beneficial in septic shock.
• The addition of fludrocortisone may be considered in some cases, although its role is uncertain.
• The benefits of corticosteroid therapy include improved shock reversal, reduced inflammation, and improved outcome.
• The risks of corticosteroid therapy, such as superinfection, must also be considered.