Steroids for septic shock: back from the dead? (Con).
The role of corticosteroid therapy in the management of septic shock has been debated for half a century. Results from large, well-designed, randomized clinical trials demonstrate no benefit, and perhaps harm, associated with short duration, high-dose methylprednisolone or dexamethasone administered at the onset of septic shock. Based on evidence of "relative adrenal insufficiency" and steroid-responsive adrenergic receptor desensitization in sepsis, administration of modest doses (200 to 300 mg/d) of hydrocortisone for 1 to 3 weeks has been investigated. A multicenter, placebo-controlled clinical trial demonstrated improved survival rates and faster cessation of vasopressors among patients with septic shock who have a poor response to corticotropin injection, consistent with relative adrenal insufficiency. However, concerns regarding a trend for higher mortality among corticotropin responders and the possibility that patients with true adrenal insufficiency may have been enrolled in this placebo-controlled trial, potentially skewing results, should be considered.
Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Medical College of Virginia Hospitals, Richmond 23298, USA. csessler@hsc.vcu.edu
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D000309:Adrenal Insufficiency / Q000150:complications; D005938:Glucocorticoids / Q000627:therapeutic use*; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D008775:Methylprednisolone / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012772:Shock, Septic / Q000150:complications / Q000188:drug therapy*
D005938:Glucocorticoids; D006854:Hydrocortisone; D008775:Methylprednisolone