Wednesday January 4, 2006
Low dose steroid, yes or no ? - responder or non-responder ? - low-dose corticotropin stimulation test or high dose?
Role of steroid in sepsis continue to puzzle physicians - "to do or not do" or "when to do" or "how to do" !!
Study of 177 patients published this month from Annane and coll. suggests that " 7-day treatment with low doses of corticosteroids was associated with better outcomes in septic shock-associated early ARDS nonresponders, but not in responders and not in septic shock patients without ARDS (responders or nonresponders)." But study of 41 patients published in Nov. 2005 issue of Critical Care Medicine suggests that "Treatment with low-dose hydrocortisone accelerates shock reversal in early hyperdynamic septic shock...immune effects appeared to be independent of adrenal reserve".
To keep record straight evidence-based guideline from SCCM at this point is: Intravenous corticosteroids (hydrocortisone 200-300 mg/day, for 7 days in three or four divided doses or by continuous infusion) are recommended in patients with septic shock who despite adequate fluid replacement require vasopressor therapy to maintain adequate blood pressure. And to identify "responders" (>9 μg/dL increase in cortisol 30-60 mins post-ACTH administration) and to discontinue therapy in these patients is optional. Clinicians should not wait for ACTH stimulation results to administer corticosteroids.
In this regard another interesting study of 46 patients from Belgium concluded that: low-dose (1 μg) corticotropin stimulation test may identify a subgroup of patients in septic shock that may go missed by the high-dose test (standard 250-μg test) and these patients may also benefit from glucocorticoid replacement therapy.
Hopefully, Corticus study (Corticosteroid Therapy of Septic Shock) will have some definite answer?. Let see.
References: Click on article to get abstract/article
1. Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Critical Care Medicine. 34(1):22-30, January 2006.
2. Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock. Critical Care Medicine. 33(11):2457-2464, November 2005.
3. Use of corticosteroid therapy in patients with sepsis and septic shock: An evidence-based review. Critical Care Medicine. 32(11) Supplement:S527-S523, November 2004.
4. Relative adrenal insufficiency in patients with septic shock: Comparison of low-dose and conventional corticotropin tests. Critical Care Medicine. 33(11):2479-2486, November 2005.
5. Corticosteroid Therapy of Septic Shock – Corticus - clinicaltrials.gov