UMEM Educational Pearls

Title: Is there a benefit to steroids in septic shock?

Keywords: sepsis, septic shock, glucocorticoids, steroids, hydrocortisone (PubMed Search)

Posted: 1/29/2018 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

As hospital volumes increase and ED patient boarding becomes more commonplace, emergency physicians may find themselves managing critically ill patients beyond the initial resuscitation.

The benefit of glucocorticoids in critically ill patients with septic shock has remained a topic of controversy for decades due to conflicting studies, including the 2002 Annane trial and the 2008 CORTICUS trial, which had opposing results when it came to the mortality benefit of steroids.

The results of the eagerly-awaited ADRENAL trial, a multicenter randomized controlled trial investigating the benefit of steroids in septic shock, were released earlier this month:

3658 patients from 69 different medical and surgical ICUs
Adults with septic shock requiring mechanical ventilation (including noninvasive) and vasopressors/inotropes for at least 4 hours
Continuous infusion hydrocortisone 200mg/day vs placebo for 7 days or until ICU discharge, if shorter
No mortality benefit at 90 days (primary outcome) or at 28 days (secondary outcome)
Other secondary outcomes:
- Hydrocortisone group = Shorter ICU LOS, shorter duration of shock, shorter duration of initial mechanical ventilation, fewer # of patients receiving a blood transfusion
- No difference in: mortality at 28 days, hospital LOS, recurrence of shock, total vent-free days, mean volume of blood transfused in patients receiving blood products, use of renal replacement therapy, development of new bacteremia/fungemia

Take Home Points:

1. Administration of standard daily dose hydrocortisone by infusion does not seem to affect mortality in septic shock.

2. Emergency providers should continue to consider stress-dose steroids in patients with shock and a high risk of adrenal insufficiency (e.g., chronic steroid therapy, genetic disorders, infectious adrenalitis, etc).

References

Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002; 288(7):862-71.
Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008; 358(2): 111-24.
Balasubramanian V, Finfer S, Cohen J, et al. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018; doi: 10.1056/NDJMoa1705835. [Epub ahead of print]