Steroids and insulin in septic shock

Despite the recent diminution in the indications for corticosteroids in septic shock, they are still used in limited situations, particularly when hypotension is refractory to pressor agents. When glycemic control deteriorates during the use of steroids should it be approached differently? A new JAMA study looked at this question and investigated the effect of fludrocortisone as a secondary objective:

Patients were randomly assigned to 1 of 4 groups: continuous intravenous insulin infusion with hydrocortisone alone, continuous intravenous insulin infusion with hydrocortisone plus fludrocortisone, conventional insulin therapy with hydrocortisone alone, or conventional insulin therapy with intravenous hydrocortisone plus fludrocortisone. Hydrocortisone was administered in a 50-mg bolus every 6 hours, and fludrocortisone was administered orally in 50-µg tablets once a day, each for 7 days...

Conclusions Compared with conventional insulin therapy, intensive insulin therapy did not improve in-hospital mortality among patients who were treated with hydrocortisone for septic shock. The addition of oral fludrocortisone did not result in a statistically significant improvement in in-hospital mortality.