Transcript Surviving Sepsis Campaign Guidelines for Management of

Steroid Therapy
Steroid Therapy: The French multi-center RCT
(hypotension despite fluid resuscitation and vasopressors)
Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and
fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871.
Conclusion
Significant shock reversal and reduction of
mortality rate in patients with relative
adrenal insufficiency (defined as postadrenocorticotropic hormone (ACTH)
cortisol increase 9 µg/dL or less)
Corticosteroid Therapy of Septic
Shock
CORTICUS
European multi-center RCT
Hydrocortisone Therapy for Patients
with Septic Shock
Charles L. Sprung, M.D., Djillali Annane, M.D., Ph.D., Didier Keh, M.D., Rui Moreno,
M.D., Ph.D., Mervyn Singer, M.D., F.R.C.P., Klaus Freivogel, Ph.D., Yoram G. Weiss,
M.D., Julie Benbenishty, R.N., Armin Kalenka, M.D., Helmuth Forst, M.D., Ph.D.,
Pierre-Francois Laterre, M.D., Konrad Reinhart, M.D., Brian H. Cuthbertson, M.D.,
Didier Payen, M.D., Ph.D., Josef Briegel, M.D., Ph.D., for the CORTICUS Study Group
N Engl J Med
Volume 358(2):111-124
January 10, 2008
Kaplan-Meier Curves for Survival at 28 Days
Conclusion
 Hydrocortisone did not improve survival
or reversal of shock in patients with
septic shock, either overall or in patients
who did not have a response to
corticotropin, although hydrocortisone
hastened reversal of shock in patients in
whom shock was reversed
Annane vs Sprung
Annane
Sprung
Setting
Multicenter: 19 ICUs in
France
Multicenter 52 ICUs in
Europe
Patients
300
499
SAPS II
58.5
49.5±17.8
Inclusion
Systolic blood pressure
was less than 90 mm Hg
for more than 1 hour
despite fluid and
vasopressor
Systolic blood pressure of
<90 mm Hg despite
adequate fluid
replacement or a need for
vasopressors for at least
1 hour
Enrollment window
8 hours
72 hours
Medication
Hydrocortisone +
fludrocortisone
Hydrocortisone
Medication stop
Abrupt after 7 days
Taper over 6 days
28 Day Placebo Death
61%
32%
Streoid Therapy
o Consider intravenous hydrocortisone for adult septic shock when
hypotension remains poorly responsive to adequate fluid
resuscitation and vasopressors. (2C)
o ACTH stimulation test is not recommended to identify the subset of
adults with septic shock who should receive hydrocortisone. (2B)
o Hydrocortisone is preferred to dexamethasone. (2B)
o Fludrocortisone (50µg orally once a day) may be included if an
alternative to hydrocortisone is being used which lacks significant
mineralocorticoid activity. Fludrocortisone is optional if
hydrocortisone is used. (2C)
o Steroid therapy may be weaned once vasopressors are no longer
required. (2D)
 Hydrocortisone dose should be ≤300 mg/day. (1A)
 Do not use corticosteroids to treat sepsis in the absence of shock
unless the patient’s endocrine or corticosteroid history warrants it.
(1D)