What is the role of stress-dosed steroids in the management of septic shock?

From the Guidelines

Stress-dose steroids are recommended for patients with septic shock who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy, with a suggested dose of intravenous hydrocortisone 200 mg per day. This recommendation is based on the most recent and highest quality study available, which suggests that hydrocortisone therapy may be beneficial in patients with septic shock who are unresponsive to fluid and vasopressor therapy 1. The use of stress-dose steroids in septic shock aims to enhance vascular tone, increase sensitivity to catecholamines, and modulate the inflammatory response.

Key Considerations

• The decision to initiate stress-dose steroids should be based on the patient's hemodynamic status, rather than the results of an ACTH stimulation test 1.
• Patients with a history of adrenal insufficiency or those on chronic steroid therapy should receive stress-dose steroids immediately upon presentation with septic shock, regardless of hemodynamic status.
• Blood glucose levels should be monitored closely as hyperglycemia is a common side effect of steroid therapy.
• The benefit of steroids appears greatest in patients with the most severe shock, particularly those requiring high-dose vasopressors.

Administration and Monitoring

• The preferred regimen is intravenous hydrocortisone 200 mg per day, which can be administered as a continuous infusion or divided into 3-4 doses.
• For practical administration, this typically means hydrocortisone 50 mg IV every 6 hours or 100 mg IV every 8 hours.
• Patients should be closely monitored for signs of improvement or deterioration, and the steroid dose should be adjusted accordingly.

Evidence Summary

The recommendation for stress-dose steroids in septic shock is based on the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1, which suggests that hydrocortisone therapy may be beneficial in patients with septic shock who are unresponsive to fluid and vasopressor therapy. Additional guidance is provided by the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017 guidelines 1, which recommend the use of corticosteroids in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy.

From the FDA Drug Label

In patients on corticosteroid therapy subjected to unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated.

The role of stress-dosed steroids in the management of septic shock is to provide increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation, such as septic shock, in patients who are already on corticosteroid therapy. This is indicated to help the body respond to the stress of septic shock. 2

From the Research

Role of Stress-Dosed Steroids in Septic Shock Management

• The use of stress-dosed steroids, such as hydrocortisone, in septic shock management is a topic of ongoing debate 3, 4, 5, 6, 7
• Current guidelines recommend considering corticosteroids in patients with vasopressor and fluid-resistant septic shock 4
• Studies have shown that physiologic-dose steroids can reduce vasopressor requirements and improve time to shock resolution 4, 6
• However, the mortality benefit of corticosteroids in septic shock is still controversial, with some studies showing no effect 3, 4, 7
• The use of fludrocortisone in addition to hydrocortisone has been evaluated, but its effectiveness and safety are still unknown 7

Patient Selection and Steroid Regimen

• Patients with septic shock who are more severely ill may be more likely to receive stress-dosed steroids 3
• The decision to use continuous or intermittent steroid infusion varies widely in clinical practice 5
• The optimal dose and duration of hydrocortisone therapy in septic shock are still unclear 6
• Further studies are needed to determine the best corticosteroid regimen for patients with septic shock refractory to fluids and vasopressors 7

Clinical Outcomes

• Studies have shown that patients who receive stress-dosed steroids may have higher hospital mortality rates 3
• However, multivariable adjustment has shown no association between receipt of hydrocortisone and hospital mortality 3
• The use of fludrocortisone plus hydrocortisone was not associated with improved clinical outcomes, including time to shock reversal and in-hospital mortality 7
• Hyperglycemia was more frequent in patients who received fludrocortisone plus hydrocortisone 7