Anesthesia Management: More Support for Using Steroids in Patients with Refractory Septic Shock

This is for our anesthesia providers who also perform critical care medicine.

Authors: Funk D et al., Crit Care Med 2014 Nov 42:2333

In an observational study, steroid therapy was associated with lower mortality in the sickest patients.

The most recent Surviving Sepsis Guidelines (Crit Care Med 2013; 41:580) suggest that steroids (200 mg hydrocortisone daily) should be used only when volume resuscitation and vasopressors cannot restore hemodynamic stability. Investigators examined data on patients who were treated for septic shock at 28 hospitals in Canada, the U.S., and Saudi Arabia; 1838 patients who received low-dose steroids ( less than 80 mg prednisone equivalent daily) were compared with a propensity-matched cohort that did not. Patients were excluded if they died within 48 hours of intensive care unit (ICU) admission or received steroids later than 48 hours after documentation of shock.

ICU, hospital, and 30-day mortality did not differ between groups. In subgroup analyses, 30-day mortality in the highest Acute Physiology and Chronic Health Evaluation (APACHE) II quartile (i.e., the sickest patients) was significantly lower in the steroid group (50.6% vs. 55.8%). Unlike in previous studies, steroid administration was not associated with shorter time to resolution of shock. Among patients who were the least sick, those who received steroids versus those who did not had a nonsignificant trend toward higher mortality.

Comment
The pendulum continues to swing back and forth on whether patients with septic shock should be treated with corticosteroids. Although we still don’t have a definitive answer, this large retrospective study supports the common practice of giving steroids to the sickest patients with refractory septic shock. This is a reasonable practice in patient populations with very high mortality.