Four misconceptions and one truth
Misconception #1: Stress-dose steroids decrease mortality
Misconception #2: Stress-dose steroids increase the risk of secondary superinfection
Truth: Stress-dose steroid reduces the duration of septic shock
Misconception #3: The Annane et al. and CORTICUS studies conflict each other
Misconception #4: The benefit of steroids is limited to patients with vasopressor-refractory shock
The use of steroids in sepsis may be similar to their use in COPD
Thus, steroids in sepsis are neither as awesome nor as scary as is often believed. Steroids won't improve mortality, but neither will they lead to terrible superinfections. The primary benefit of steroids may simply be to reduce the duration of shock. This shouldn't be a huge surprise because stress dose steroids (200 mg/day hydrocortisone) are equivalent of 50 mg prednisone daily, a commonly used dose which is fairly safe in short courses.
For now, how should we use steroids?
- Misconception #1 = Stress-dose steroids can improve mortality. (Evidence: There is no convincing data that stress-dose steroids improve mortality.)
- Misconception #2 = Stress-dose steroids increase risk of superinfection. (Evidence: There is no statistically significant increase in the rate of superinfection.)
- Misconception #3 = Annane et al. and CORTICUS, the two major trials investigating stress dose steroids in septic shock, obtained conflicting results. (Evidence: The raw data from these studies is consistent.)
- Misconception #4 = The benefit of stress dose steroid is restricted to patients with vasopressor-refractory septic shock. (Evidence: There is no clear demarcation of which patients may or may not benefit from steroids.)
- Truth = Stress-dose steroids consistently reduce the duration of septic shock.
- Overall this may be similar to the utility of steroids in COPD exacerbations: a treatment which hastens recovery and improves organ function without affecting mortality.
- Which patients may benefit from stress dose steroid remains unclear. For now, careful consideration of each patient with clinical judgment may be a reasonable approach.
Stay tuned for the culmination of this three-week series on septic shock next week.
- Fluids: Empty IVC in early sepsis doesn’t prove volume depletion
- Renoresuscitation: Overall conceptualization & strategy