What is the role of steroids, specifically hydrocortisone (corticosteroid), in the management of sepsis (systemic inflammatory response syndrome) and septic shock?

Role of Corticosteroids in Sepsis and Septic Shock Management

Hydrocortisone should NOT be used in septic shock patients if adequate fluid resuscitation and vasopressor therapy can restore hemodynamic stability, but should be administered at 200 mg/day when hemodynamic stability cannot be achieved with these measures alone. 1, 2

Patient Selection for Corticosteroid Therapy

Corticosteroid therapy in sepsis should follow these guidelines:

• Sepsis without shock: Corticosteroids should NOT be administered for sepsis in the absence of shock (Grade 1D recommendation) 1, 2

• Septic shock with hemodynamic stability: Do NOT use hydrocortisone if adequate fluid resuscitation and vasopressor therapy successfully restore hemodynamic stability 1

• Refractory septic shock: Use hydrocortisone when patients remain hypotensive despite:

  • Adequate fluid resuscitation
  • Vasopressor therapy at significant doses
  • Inability to achieve hemodynamic stability 1, 2

• ACTH stimulation testing: Not recommended to identify candidates for hydrocortisone therapy (Grade 2B) 1

Dosing and Administration Protocol

When indicated, hydrocortisone should be administered according to these parameters:

• Dose: 200 mg per day (weak recommendation, low quality of evidence) 1
• Administration methods:
  • 50 mg IV every 6 hours
  • 100 mg IV every 8 hours
  • Continuous infusion (preferred, Grade 2D) 1, 2
• Duration: At least 3 days at full dose 2
• Discontinuation: Taper when vasopressors are no longer required (Grade 2D) 1

Clinical Benefits and Outcomes

The benefits of hydrocortisone in appropriate patients include:

• Shock reversal: Faster resolution of shock and reduced time to discontinue vasopressors 2, 3
• Hemodynamic stability: Improved hemodynamic variables after treatment 4
• Anti-inflammatory effects: Decrease in pro-inflammatory cytokines (IL-1β, IFN-γ, TNF-α, IL-6) 4

Early initiation of hydrocortisone (within 3 hours) may reduce the time needed to discontinue vasopressors compared to later initiation 3.

Potential Side Effects and Monitoring

When administering hydrocortisone:

• Monitor: Blood glucose and electrolytes regularly to detect hyperglycemia, hypernatremia, and hypokalemia 2
• Common side effects: Hyperglycemia and hypernatremia 2
• Risk of superinfection: Low-dose corticosteroids do not appear to significantly increase risk 2, 5

Important Caveats and Pitfalls

• Avoid high-dose regimens: High-dose corticosteroid therapy is associated with increased harm 5
• Shock relapse: May occur after abrupt cessation of hydrocortisone, particularly with persistent infection or prior etomidate use 6
• Etomidate consideration: Etomidate suppresses the hypothalamic-pituitary-adrenal axis, which may affect response to corticosteroid therapy 1
• Dosing variations: While 200 mg/day is standard, some studies have explored 300 mg/day without significant differences in mortality or adverse events 6

The evidence supporting corticosteroid use in septic shock remains of low quality, with some systematic reviews showing reduced mortality while others show no significant difference 1, 2. The most beneficial effects may be seen in patients with higher baseline mortality risk (>60%) 1, 2.