Critical illness-related corticosteroid insufficiency medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
In adults with septic shock and refractory hypotension despite resuscitation with intravenous fluids and vasopressors, hydrocortisone is the preferred corticosteroid. It can be divided in several doses or administered as a continuous infusion.[1] Fludrocortisone is optional in CIRCI, and dexamethasone is not recommended.[2] Little evidence is available to judge when and how corticosteroid therapy should be stopped; guidelines recommend tapering corticosteroids when vasopressors are no longer needed.
Corticosteroid treatment has also been suggested as an early treatment option in patient with acute respiratory distress syndrome. Steroids have not been shown beneficial for sepsis alone.[3] Historically, higher doses of steroids were given, but these have been suggested to be harmful compared to the lower doses which are advocated today.[4]
In the CORTICUS study, hydrocortisone hastened the reversal of septic shock, but did not influence mortality, with an increased occurence of septic shock relapse and hypernatremia.[5] The latter findings tempered enthusiasm for the broad use of hydrocortisone in septic shock. Prior to this study, several other smaller studies showed beneficial effects of long courses of low doses of corticoid.[6][7][8][9][10][11][12] Several factors (such as lack of statistical power due to slow recruitment) could have led a false-negative finding on mortality in the CORTICUS study; thus, more research is needed.[13]
References
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18496365
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437
- ↑ Lefering R, Neugebauer EA (1995). "Steroid controversy in sepsis and septic shock: a meta-analysis". Crit. Care Med. 23 (7): 1294–303. PMID 7600840. Unknown parameter
|month=ignored (help) - ↑ Minneci PC, Deans KJ, Banks SM, Eichacker PQ, Natanson C (2004). "Meta-analysis: the effect of steroids on survival and shock during sepsis depends on the dose". Ann. Intern. Med. 141 (1): 47–56. PMID 15238370. Unknown parameter
|month=ignored (help) - ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18184957
- ↑ Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y (2004). "Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis". BMJ. 329 (7464): 480. doi:10.1136/bmj.38181.482222.55. PMC 515196. PMID 15289273. Unknown parameter
|month=ignored (help) - ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=12186604
- ↑ Briegel J, Forst H, Haller M; et al. (1999). "Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study". Crit. Care Med. 27 (4): 723–32. PMID 10321661. Unknown parameter
|month=ignored (help) - ↑ Bollaert PE, Charpentier C, Levy B, Debouverie M, Audibert G, Larcan A (1998). "Reversal of late septic shock with supraphysiologic doses of hydrocortisone". Crit. Care Med. 26 (4): 645–50. PMID 9559600. Unknown parameter
|month=ignored (help) - ↑ Oppert M, Schindler R, Husung C; et al. (2005). "Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock". Crit. Care Med. 33 (11): 2457–64. PMID 16276166. Unknown parameter
|month=ignored (help) - ↑ Yildiz O, Doganay M, Aygen B, Güven M, Keleştimur F, Tutuû A (2002). "Physiological-dose steroid therapy in sepsis [ISRCTN36253388]". Crit Care. 6 (3): 251–9. PMC 125315. PMID 12133187. Unknown parameter
|month=ignored (help) - ↑ Keh D, Boehnke T, Weber-Cartens S; et al. (2003). "Immunologic and hemodynamic effects of "low-dose" hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study". Am. J. Respir. Crit. Care Med. 167 (4): 512–20. doi:10.1164/rccm.200205-446OC. PMID 12426230. Unknown parameter
|month=ignored (help) - ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699