What is the role of corticosteroids (steroids) in the management of sepsis?

Role of Corticosteroids in Sepsis Management

Corticosteroids may reduce mortality by a small amount and increase recovery in patients with sepsis or septic shock, with a weak recommendation for their use in sepsis management; both using steroids and not using steroids are reasonable options depending on patient values and clinical context. 1

Patient Selection for Corticosteroid Therapy

Indications for Corticosteroid Use:

• Septic shock requiring vasopressors: Strongest indication is in patients who do not respond to adequate fluid resuscitation and require vasopressor support 1
• Vasopressor dependency: Particularly recommended in patients requiring ≥0.5 μg/kg/min of norepinephrine 2
• Relative adrenal insufficiency: May be more beneficial in patients with relative adrenal insufficiency, though diagnosis remains challenging 3

Risk Stratification:

• Patients at greatest risk of death (with shock, high qSOFA/SOFA scores) will likely have the greatest mortality reduction with corticosteroids 1
• Patients with severe shock show most significant benefit 3

Corticosteroid Dosing and Administration

Recommended Regimen:

• Hydrocortisone: 200-300 mg/day for at least 5-7 days, followed by a tapering dose 1, 2
• Duration: Continue for 5-7 days except in patients with poor hemodynamic response after 2 days who have a cortisol increment >250 nmol/L after ACTH test 2
• Potential addition: Consider combining with enteral fludrocortisone at 50 μg daily 2, though the role of fludrocortisone remains uncertain 3

Important Dosing Considerations:

• Low-dose approach: Current evidence supports low-dose, longer-duration therapy (200-300 mg hydrocortisone for 5-7 days) 3
• Avoid high doses: Short-term therapy with high doses (up to 42g hydrocortisone equivalent for 1-2 days) has been ineffective or potentially harmful 3
• Pediatric dosing: 1 mg/kg hydrocortisone every 6 hours 1

Expected Benefits and Monitoring

Potential Benefits:

• Improved shock reversal 3, 4
• Reduced inflammation 3
• Possible mortality reduction 4
• Shortened ICU stay 4

Monitoring During Treatment:

• Blood glucose: Keep levels below 150 mg/dL 2
• Hemodynamic parameters: Monitor for improvement in shock reversal
• Inflammatory markers: Assess reduction in inflammation
• Organ function: Monitor for improvement

Limitations and Considerations

Clinical Controversies:

• Conflicting evidence from major trials has led to debate about universal application 1
• Uncertainty about restricting treatment to patients with relative adrenal insufficiency 3
• Diagnosis of relative adrenal insufficiency is highly dependent on cut-off values and definition 3

Patient-Centered Decision Making:

• Patients who prioritize avoiding death over quality of life may prefer corticosteroid treatment 1
• Those who prioritize avoiding functional deterioration and maximizing quality of life may choose not to use corticosteroids 1

Implementation in Clinical Practice

Integration with Other Sepsis Management:

• Early, broad-spectrum antibiotics remain the cornerstone of sepsis management 1
• Adequate fluid resuscitation should be ensured before considering corticosteroids 1
• Vasopressors (preferably noradrenaline) should be initiated if MAP <65 mmHg despite adequate fluid resuscitation 1

Common Pitfalls to Avoid:

• Delaying appropriate antibiotic therapy while considering steroid use
• Using high-dose, short-duration corticosteroid regimens
• Failing to monitor for hyperglycemia during corticosteroid therapy
• Not considering tapering doses when discontinuing treatment
• Overreliance on corticosteroids without addressing the underlying infection source

The decision to use corticosteroids in sepsis should be made based on the patient's clinical status, particularly focusing on those with vasopressor-dependent septic shock who stand to gain the most benefit while weighing the potential risks.