SUMMARY:

• Corticosteroid use in the treatment of sepsis has been ongoing for half a century.

• Despite this long-term evaluation, there is still widespread disagreements regarding their risk-to-benefit ratio.

• Current evidence does not support the use of corticosteroids either alone or in combination to improve sepsis mortality or organ dysfunction in septic shock.

BACKGROUND:

THE RATIONALE FOR CORTICOSTEROIDS

• The use of corticosteroids in sepsis is based on their immunosuppressive properties in the face of uncontrolled systemic inflammation with sepsis.

• Corticosteroids also activate mineralocorticoid and glucocorticoid receptors which can help counter sepsis-induced hypovolemia by increasing sodium retention.

• Corticosteroids can also improve alpha agonist responsiveness which can help increase systemic vascular resistance and elevate mean arterial pressure.

THE RATIONALE AGAINST CORTICOSTEROIDS

• Corticosteroids can suppress the immune system., potentially allowing the underlying infection to worsen.

• Their immunosuppressive properties can increase the risk of secondary infections, worsening the patient’s condition.

• Corticosteroids can increase serum glucose values, mainly with bolus doses.

• Corticosteroids can cause fluid retention and electrolyte imbalance, these may contribute to sepsis-induced organ dysfunction (i.e. acute kidney injury).

REVIEW:

• Recently, studies evaluating corticosteroids in sepsis have been used in combination with vitamin C and thiamine.

• The potential benefit of combination therapy is to preserve endothelial function by including anti-inflammatory and antioxidant properties.

• However, studies have not demonstrated a significant improvement in primary or secondary outcomes including:

• • Changes in SOFA score at 72 hours
  • Kidney failure
  • 30-day mortality
  • Ventilator free days
  • ICU-free days

• A significant increase in shock-free days has been reported with the corticosteroid treatment group.

CONCLUSIONS:

• Based on data demonstrating limited value, the Surviving Sepsis Campaign recommendation of corticosteroid administration only applies to adults with septic shock requiring ongoing vasopressor support (greater than 4 hours).

• After 50 years, we still do not have a definitive answer.

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Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (erkan@spo.icu), or video chat.