Friday, October 21, 2011

Corticosteroids in septic shock---current state of the controversy

The use of steroids in patients with septic shock is controversial. The Annane study in 2002 showed benefit and was followed by enthusiasm for the use of steroids. But several years later the CORTICUS paper , the largest study to date, showed no benefit of steroids. That didn't settle things, however. The CORTICUS patients were much less ill than the Annane study patients and debate continued. A meta-analysis published a short time later suggested benefit from steroids. Some patients clearly benefit. The trick is in knowing which ones. There is no basis in high level evidence to come down strongly for or against steroids as a general recommendation. The Surviving Sepsis guidelines recommend consideration of steroid use in patients poorly responsive to pressors after volume optimization.

Where do things stand now? In a recent commentary (HT to the EM Crit blog) in the journal Critical Care Dr. Paul Marik attempts to synthesize the evidence and offer updated recommendations. His recommendations are similar to those of the guidelines. As a specific indication of poor responsiveness to pressors, he considers the requirement of 0.1 mcg/kg/min of norepi (or the equivalent) as a sign that corticosteroids are indicated.

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