When to administer corticosteroids (steroids) for patients with septic shock?

From the Guidelines

Corticosteroids should be administered to patients with septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy, with a recommended dose of 200 mg per day of intravenous hydrocortisone. 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 corticosteroids in septic shock is intended to reduce inflammation, improve vascular tone, and enhance sensitivity to catecholamines, thereby potentially addressing relative adrenal insufficiency that occurs in critical illness.

Key Considerations

• The decision to administer corticosteroids should be based on the patient's response to initial fluid resuscitation and vasopressor therapy, rather than on the results of an adrenocorticotropic hormone (ACTH) stimulation test 1, 2.
• The recommended dose of hydrocortisone is 200 mg per day, which can be administered as a continuous infusion or in divided doses 1, 3.
• Treatment with corticosteroids should be initiated within the first 6-12 hours of shock onset for maximum benefit, and should be discontinued once vasopressors are no longer needed and the patient is hemodynamically stable 1.
• Potential side effects of corticosteroid therapy include hyperglycemia, which should be monitored and managed with insulin as needed, as well as increased risk of secondary infections and impaired wound healing with prolonged use.

Administration and Monitoring

• When hydrocortisone is given, it is recommended to use continuous flow, rather than intermittent boluses 1, 3.
• Patients receiving corticosteroid therapy should be closely monitored for signs of adverse effects, including hyperglycemia, secondary infections, and impaired wound healing.
• The use of corticosteroids in septic shock should be individualized based on the patient's specific clinical circumstances, and should be guided by the most recent and highest quality evidence available 1, 2, 3.

From the Research

Administration of Corticosteroids in Septic Shock

• The use of corticosteroids in septic shock is controversial, but they may be considered in patients with vasopressor and fluid-resistant septic shock 4.
• Physiologic-dose corticosteroids, such as hydrocortisone, may decrease the need for vasopressors and improve the time to shock resolution 4, 5.
• The Surviving Sepsis Campaign advises consideration of corticosteroids in patients with vasopressor and fluid-resistant septic shock 4.
• A suggested regimen is hydrocortisone 100 mg intravenously every 8 hours or 50 mg intravenously every 6 hours 4.

Patient Selection and Timing

• Patients with vasopressor-resistant septic shock and no contraindications to corticosteroids may benefit from corticosteroid therapy 4.
• Corticosteroids should be administered within 6 hours of initiating vasopressor therapy 6.
• The use of corticosteroids is recommended for septic shock patients with escalating doses of vasopressors and evidence of multiorgan dysfunction 7.

Benefits and Risks

• Corticosteroids consistently lead to a faster reversal of shock and may shorten the duration of mechanical ventilation 7.
• The mortality benefit of corticosteroids appears to be greatest in septic shock patients with high vasopressor requirements, evidence of multiorgan failure, and primary lung infections 7.
• Corticosteroids do not seem to increase the risk of superinfection at low doses but frequently lead to a higher frequency of hyperglycemia 7.
• The risk of superinfection is not suggested by the majority of studies 4.