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Low-Dose Steroids in Septic Shock

Hydrocortisone-fludrocortisone therapy reduced mortality among patients with septic shock and impaired adrenal reserve.

The idea that low-dose corticosteroids might improve outcomes in patients with septic shock is making a comeback: Interest has been fueled by observations that many critically ill patients appear to have impaired adrenal reserve. In a double-blind study, French researchers randomized 300 patients with septic shock to receive 7-day courses of hydrocortisone (50 mg intravenously every 6 hours) plus fludrocortisone (50-µg tablet once daily), or placebo. The patients all had strongly suspected or documented infection, hypotension, need for mechanical ventilation, and several other indicators of organ dysfunction. All patients underwent short corticotropin stimulation tests before they started steroid therapy.

Among the 229 patients who did not respond to corticotropin (indicating impaired adrenal reserve), 28-day mortality was significantly lower in the steroid group than in the placebo group (53% vs. 63%; P=0.04). In addition, the median time to withdrawal of vasopressor therapy was significantly shorter in the steroid group. In contrast, among patients who did respond to corticotropin, mortality did not differ significantly between steroid and placebo groups. No adverse events attributable to steroids were noted.

Comment: These results suggest that many patients with septic shock have relative adrenal insufficiency and that steroids may be beneficial in such cases. The authors and 2 editorialists recommend that patients with septic shock undergo corticotropin stimulation tests, followed by initiation of hydrocortisone-fludrocortisone therapy; when the test results become available, steroids should be continued in corticotropin nonresponders and discontinued in corticotropin responders.

— Allan S. Brett, MD

Published in Journal Watch General Medicine August 30, 2002

Citation(s):

Annane D et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002 Aug 21; 288:862-71.

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Abraham E and Evans T. Corticosteroids and septic shock. JAMA 2002 Aug 21; 288:886-7.

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