What is the role of steroids, such as hydrocortisone, in the management of shock, particularly septic shock?

Role of Steroids in Shock Management

Steroids should not be used in septic shock if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability; however, IV hydrocortisone at 200 mg/day is recommended when shock persists despite these measures. 1

Patient Selection for Steroid Therapy

When to Use Steroids:

• Only in septic shock patients who remain hypotensive despite:
  • Adequate fluid resuscitation
  • Vasopressor therapy 1, 2
• No need for ACTH stimulation test to identify candidates for hydrocortisone therapy 1
• Most beneficial effects seen in patients with:
  • High vasopressor requirements
  • Evidence of multiorgan failure
  • Primary lung infections 2

When NOT to Use Steroids:

• Sepsis without shock (strong recommendation, Grade 1D) 1, 2
• Patients who achieve hemodynamic stability with fluids and vasopressors alone 1

Dosing and Administration

Recommended Protocol:

• Dose: 200 mg/day of hydrocortisone 1, 2
• Administration options:
  • 50 mg IV every 6 hours
  • 100 mg IV every 8 hours
  • Continuous infusion 2
• Duration: At least 3 days at full dose or until vasopressors are no longer required 2
• Continuous flow administration is preferred (Grade 2D) 1

Clinical Benefits and Outcomes

Proven Benefits:

• Faster shock reversal and reduced time to discontinue vasopressors 1, 3, 4
• Early initiation (within 3 hours) may reduce time needed to discontinue vasopressors compared to later initiation 3

Impact on Mortality:

• Evidence on mortality benefit is mixed:
  • Some systematic reviews show reduced 28-day mortality with low-dose steroid treatment 1
  • Other analyses show no statistically significant difference in mortality 1, 4
  • Most beneficial effects may be seen in patients with higher baseline mortality risk (>60%) 1

Discontinuation Strategy

Tapering Approach:

• Hydrocortisone should be tapered when vasopressors are no longer required (Grade 2D) 1
• Abrupt discontinuation should be avoided due to risk of hemodynamic and immunologic rebound effects 2, 5
• Common tapering methods include reduction in frequency (most common) or dose 5
• Typical taper duration is 1-3 days 5

Monitoring During Taper:

• Watch for increased vasopressor requirements during the first 24-48 hours of taper initiation 5
• Monitor for signs of adrenal insufficiency during and after taper

Potential Adverse Effects

• Hyperglycemia and hypernatremia are common side effects 2
• Increased risk of superinfection, including new sepsis and septic shock 4
• Regular monitoring of blood glucose and electrolytes is necessary 2

Special Considerations

• Patients with a history of steroid therapy or adrenal dysfunction require special attention 2
• Approximately 25% of patients with septic shock develop relative adrenal insufficiency 2
• Etomidate use for intubation can suppress the hypothalamic-pituitary-adrenal axis and may affect outcomes when combined with steroid therapy 1

By following these evidence-based recommendations, clinicians can appropriately incorporate steroids into the management of septic shock while minimizing potential adverse effects and optimizing patient outcomes.