Steroids

Question 1

ANNENE (2002) The French Trial

Answer 1

Among patients with septic shock and relative adrenal insufficiency, administration of corticosteroids reduces 28-day mortality, although this finding was not confirmed in the follow-up CORTICUS trial. Among nonresponders, corticosteroid use was associated with a 10% absolute reduction in 28-day mortality (53% vs. 63%), although there was no difference at one year (68% vs. 77%). Corticosteroids were also associated with a more rapid reversal of shock.

Question 2

CORTICUS (2008)

Answer 2

Hydrocortisone does not improve survival in patients with septic shock, regardless of response to ACTH. While there was no survival benefit, hydrocortisone conferred a more rapid reversal of shock in all subgroups studied.

Question 3

CRASH-1 (2014)

Answer 3

In patients with a head injury, patients who received a steroid had worse outcomes compared to the placebo group (21% mortality vs. 18% mortality, RR1.18, CI 1.09-1.27, p=0.00001)

Question 4

HYPRESS (2016)

Answer 4

In patients with severe sepsis, hydrocortisone in the first 48 hours did not reduce progression to septic shock at 14 days compared to placebo. Hydrocortisone therapy also failed to result in improvement in time to septic shock or short- or intermediate-term mortality. Hydrocortisone was associated with a 10% absolute increase in hyperglycemia and an absolute 13% reduction in delirium

Question 5

COIITSS (2018)

Answer 5

There was no significant difference between intensive insulin therapy (4-6 mol/dl) and conventional glucose control (<8.3mmol/dl). This trial provides no evidence to support intensive insulin therapy for patients being treated with Corticosteriods for septic shock.
Based in France, n= 509

Question 6

ADRENAL (2018)

Answer 6

In patients with septic shock on mechanical ventilation and receiving vasopressors, a week of hydrocortisone 200 mg/day did not reduce 90 day mortality but may be associated with time until reversal of shock, time to extubation, length of ICU stay, and blood transfusion.

Question 7

Surviving Sepsis Campaign severe sepsis and septic shock (2016)

Answer 7

If adequate fluid resuscitation and vasopressor therapy can restore hemodynamics, suggest against using IV hydrocortisone (weak recommendation, low quality of evidence)
If above isn’t achievable, suggest hydrocortisone 200 mg IV per day (weak recommendation, low quality of evidence).

Question 8

APPROCCHS (2018)

Answer 8

Among mechanically ventilated patients with septic shock and very high risk of mortality, the use of hydrocortisone with fludrocortisone reduces the mortality and vasopressor requirements.