Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study.
BACKGROUND
The use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock.


METHODS
We retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality.


RESULTS
The study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54 to 71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8 to 19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours versus 10.4 hours; P=0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P=0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (P<0.0001) and Sequential Organ Failure Assessment (SOFA) scores (P=0.0007), dose of vasopressor at the time of initiation of low-dose corticosteroid therapy (P<0.0001), need for mechanical ventilation (P=0.0001) and renal replacement therapy (P<0.0001), while the impaired adrenal reserve did not affect 28-day mortality (81% versus 82%; P=0.8679). After adjusting for potential confounding factors, the time to initiation of low-dose corticosteroid therapy was still significantly associated with 28-day mortality (adjusted odds ratio (OR) 1.025, 95% confidence interval (CI) 1.007 to 1.044, P=0.0075). The early therapy group (administered within 6 hours after the onset of septic shock, n=66) had a 37% lower mortality rate than the late therapy group (administered more than 6 hours after the onset of septic shock, n=112) (32% versus 51%, P=0.0132).


CONCLUSIONS
Early initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea.
Hye Yun
HY
Park
Gee Young
GY
Suh
Jae-Uk
JU
Song
Hongseok
H
Yoo
Ik Joon
IJ
Jo
Tae Gun
TG
Shin
So Yeon
SY
Lim
Sookyoung
S
Woo
Kyeongman
K
Jeon
D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000368:Aged; D015331:Cohort Studies; D019468:Disease Management; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
D000305:Adrenal Cortex Hormones