Clinical Effect of Systemic Steroids in Patients with Cirrhosis and Septic Shock

Abstract

Evidence regarding the utility of systemic steroids in treating patients with cirrhosis and septic shock remains equivocal. This study aimed to evaluate and elucidate the association of steroid use with outcomes and adverse effects in a cohort of patients with cirrhosis and septic shock. Patients and methods: Retrospective cohort study of patients with cirrhosis and septic shock admitted to a tertiary hospital intensive care unit (ICU) from January 2007 to May 2017, using a validated ICU Datamart. Patients who received vasopressors within 6 h of ICU admission were included in the multivariate analysis. The effect of steroids on outcomes was evaluated using multivariable regression, adjusting for confounding variables. Results: Out of 179 admissions of patients with cirrhosis and septic shock, 56 received steroids during the ICU admission. Patients who received steroids received a higher total dose of vasopressors (91.2 mg vs. 39.1 mg, P ¼ 0.04) and had a lower initial lactate level (1.8 mmol/L vs. 2.6 mmol/L, P ¼ 0.007). The multivariate analysis included 117 patients and showed no significant differences in mortality, length of ICU admission, or length of hospital stay. Bleeding events, delirium, and renal-replacement therapy requirements were also not associated with the use of steroids. Conclusion: The use of systemic steroids was more prevalent in cirrhotic patients with higher vasopressor requirements. It was not associated with decreased mortality or increased ICU-and hospital-free days, or to adverse effects.

Management of sepsis in a cirrhotic patient admitted to the intensive care unit: A systematic literature review

“…Corticosteroids: Arabi et al [ 13 ] concluded that corticosteroids improved the hemodynamic status of the patient but did not change mortality (Table 1 ). Rinaldi et al [ 5 ] and Piccolo Serafim et al [ 14 ] found similar results to Arabi et al [ 13 ] (Tables 2 and 3 ).…”

“…Nevertheless, its use in liver cirrhosis remains controversial[ 7 ]. Hydrocortisone improves the hemodynamic status of the patient without a relevant change in mortality[ 13 , 14 , 18 ]. Hydrocortisone is associated with better shock resolution, although without an impact on survival[ 5 ].…”

Emerging concepts in the care of patients with cirrhosis and septic shock

“…Patients treated in the corticosteroid arm had a higher incidence of shock relapse, which supports the notion of unmasked RAI. A higher incidence of gastrointestinal bleeding was observed in the Arabi trial, but this was not replicated in larger observational studies[ 146 ]. Despite the mixed evidence, SSC guidelines currently recommend the use of corticosteroids in patients with refractory shock[ 45 ].…”

Cirrhosis Management in the Intensive Care Unit

“…A retrospective cohort study demonstrated that use of systemic corticosteroids in patients with cirrhosis and septic shock was not found to reduce mortality or length of ICU and hospital stay. 93 A large, multicenter trial found that hydrocortisone alone did not reduce mortality compared with placebo, 94 while another study found the combination of hydrocortisone and fludrocortisone to improve 90-day survival in septic shock. 95 Although corticosteroids' general role in shock resuscitation remains undefined, their use in the setting of relative adrenal insufficiency should be entertained and will be discussed later.…”