What is the recommendation for corticosteroid (steroid) use in septic shock patients as per Surviving Sepsis Guidelines (SSG)?

Corticosteroid Use in Septic Shock: Surviving Sepsis Guidelines

The Surviving Sepsis Campaign (2016) recommends AGAINST routine use of IV hydrocortisone in septic shock patients who achieve hemodynamic stability with adequate fluid resuscitation and vasopressor therapy, but SUGGESTS hydrocortisone 200 mg/day for patients with refractory septic shock who remain hypotensive despite these interventions. 1

Primary Recommendation

Reserve hydrocortisone for vasopressor-unresponsive septic shock only - meaning patients who cannot achieve hemodynamic stability despite adequate fluid resuscitation and vasopressor therapy. 1, 2

Specific Criteria for Hydrocortisone Use:

• Dose: 200 mg/day of IV hydrocortisone (weak recommendation, low quality evidence) 1, 2
• Administration: Continuous infusion preferred over bolus dosing (grade 2D) 1, 2
• Duration: Continue for at least 3 days at full dose 3
• Tapering: Gradually taper when vasopressors are no longer required rather than abrupt discontinuation (grade 2D) - taper over 6-14 days to avoid rebound inflammation 1, 3

When NOT to Use Corticosteroids

Do NOT administer corticosteroids for sepsis in the absence of shock (strong recommendation, grade 1D). 1, 3 This is a critical distinction - sepsis without shock does not benefit from corticosteroid therapy.

Diagnostic Testing

Do NOT use the ACTH stimulation test to identify which septic shock patients should receive hydrocortisone (grade 2B). 1, 2, 3 This test has no role in guiding corticosteroid therapy decisions in septic shock.

Clinical Benefits and Limitations

Demonstrated Benefits:

• Faster shock reversal - consistently shown across studies 2, 4, 5, 6
• Reduced vasopressor requirements and shorter time to vasopressor discontinuation 4, 7, 5, 6
• May shorten duration of mechanical ventilation 5

Mortality Evidence:

The mortality benefit remains controversial and inconsistent across trials. 2, 4, 5 The evidence quality is low, with conflicting results from major trials (ADRENAL vs APROCCHSS). 5 Patients most likely to benefit appear to be those with high vasopressor requirements and multiorgan dysfunction. 5

Important Safety Considerations

Risks to Monitor:

• Hyperglycemia - most common adverse effect, requiring close glucose monitoring 3, 5
• Superinfection risk - including new sepsis episodes, though evidence is mixed 2, 4, 5
• Hypernatremia - monitor serum sodium during treatment 3

Critical Pitfall to Avoid:

Etomidate use for intubation can suppress the hypothalamic-pituitary-adrenal axis and may worsen outcomes when used before corticosteroid administration. 2, 3 Avoid etomidate in patients likely to require hydrocortisone.

Practical Implementation Algorithm

1. Confirm septic shock diagnosis with hypotension requiring vasopressors
2. Ensure adequate fluid resuscitation has been completed
3. Assess hemodynamic response to vasopressors
4. If hemodynamically stable → Do NOT give hydrocortisone 1
5. If refractory hypotension persists → Start hydrocortisone 200 mg/day as continuous infusion 1, 2
6. Continue for ≥3 days at full dose 3
7. When vasopressors discontinued → Begin gradual taper over 6-14 days 3

Additional Context

Real-world practice shows significant variation, with 34% of severe sepsis patients receiving corticosteroids globally, and concerningly, 14.2% receiving them without vasopressor therapy - which contradicts guideline recommendations. 8 The Society of Critical Care Medicine guidelines align with Surviving Sepsis recommendations, emphasizing doses <400 mg/day for ≥3 days in vasopressor-refractory shock. 3

Fludrocortisone addition to hydrocortisone is not currently recommended based on available evidence. 4, 5