Steroids in Sepsis

What do we want steroids to do? Improve Mortality Decrease Pressors Decrease Ventilator Time Decrease ICU LOS

Why do we think steroids may help? Relative adrenal insufficiency What do glucocorticoids do during stress?

The Cosyntropin Stim Test

Empiric Treatment of AI Dexamethasone 2mg IV bolus Hydrocortisone 50mg IV q6h

How to Interpret a Stim Test

Randomized to steroid supplementation or placebo Annane – Effect of Treatment with Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock (2002) Randomized to steroid supplementation or placebo Determined to be “responders” or “non-responders” by cosyntropin test 300 patients Majority on dopamine as their pressor Relatively sick patients compared to other studies Used fludrocortisone (for primary adrenal insufficiency) in addition to hydrocortisone No baseline value (15) used Mortality benefit even when controlled for etomidate

What do we want steroids to do? Improve Mortality (YES – in responders) Decrease Pressors (YES – in responders)

Randomized to steroid supplementation or placebo Sprung and Annane – Hydrocortisone Therapy for Patients with Septic Shock (2008) Randomized to steroid supplementation or placebo Determined to be “responders” or “non-responders” by cosyntropin test 499 patients Hydrocortisone only Fludrocortisone felt to be unnecessary given hydrocortisone has a mineralocorticoid effect and there is unpredictable absorption of po med Patient not as sick at baseline as in prior Annane study More people on norepi than dopamine Enrolled patients up to 72 hours after refractory septic shock developed (compared to 8 hours in the Annane study)

Mortality Not significant

Time to reversal of shock

What do steroids really do? Improve Mortality (?) Decrease Pressors (?) Decrease Ventilator Time (?) Decrease ICU LOS (?)