Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis

Abstract

; for the SepNet-Critical Care Trials Group IMPORTANCE Adjunctive hydrocortisone therapy is suggested by the Surviving Sepsis Campaign in refractory septic shock only. The efficacy of hydrocortisone in patients with severe sepsis without shock remains controversial. OBJECTIVE To determine whether hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock.

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

“…Earlier shock resolution has been shown to lead to lower mortality [33]. However, no studies compared the prognostic value of hemodynamic response to hydrocortisone versus the 250-µg ACTH test for the diagnosis of CIRCI.…”

“…Most recently, the HYPRESS multicenter trial assigned patients with sepsis (excluding those with shock) to receive either a continuous infusion of 200 mg of hydrocortisone for 5 days, followed by dose tapering until day 11 (n = 190), or placebo (n = 190) [33]. The primary outcome was development of septic shock within 14 days.…”

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

“…published a meta‐analysis, including their previous RCT (French study),156 which showed that low‐dose corticosteroids significantly decreased mortality rate, in addition to an improvement in the proportion of shock reversal, shortening of vasopressor therapy periods, and without an increase in adverse events. In contrast, an RCT, the Corticosteroid Therapy of Septic Shock (CORTICUS) study, with a sample size of 500, reported no improvement in 28‐day mortality rate and an increase in the incidence of complications, including infection, hyperglycemia, and hypernatremia in 2008 157. There are criticisms that the severity of the condition of patients enrolled into the CORTICUS study was lower, while the timing of initial corticosteroid therapy was later than those of the patients enrolled into the French study.…”

“…In 2016, Keh et al . showed that the administration of corticosteroids to patients with severe sepsis but without septic shock, did not reduce the incidence of shock and mortality rate by a randomized clinical trial (RCT; the HYPRESS [Hydrocortisone for Prevention of Septic Shock] Randomized Clinical Trial) 157. Based on these findings, the use of corticosteroids is not recommended for septic patients, who are not in shock or who have recovered from shock following initial fluid resuscitation and administration of vasopressors.…”

Systemic inflammatory response syndrome, sequential organ failure assessment, and quick sequential organ failure assessment: more pieces needed in the sepsis puzzle

“…If this were the case, enrollment of septic patients according to the recent sepsis-3 criteria might lead to even more negative clinical trials. As an example, a prospective, multicenter, placebocontrolled, randomized clinical trial found that use of hydrocortisone did not reduce the risk of septic shock among adults with severe sepsis not in septic shock (12). Contrary to the above deductions, Williams and coworkers reported that 30-day mortality associated with organ dysfunction based on sepsis-2 (severe sepsis) and sepsis-3 was similar (12.5% vs. 11.4%, difference 1.0%, 95% confidence interval −1.1% to 3.2%) (7).…”