Do low dose steroids improve outcome in septic shock?
Date First Published:
October 10, 2004
Last Updated:
October 11, 2004
Report by:
Bernard A Foëx, Consultant in Emergency Medicine and Critical Care (Manchester Royal Infirmary)
Three-Part Question:
In adults with [severe sepsis or septic shock] do [low dose steroids] improve [outcome]?
Clinical Scenario:
You were called to see a 56 year old woman who was admitted to a medical ward two days before with a right basal pneumonia. She was in respiratory failure, hypotensive and oliguric. After intubation, ventilation, resuscitation with fluids she remains hypotensive and a vasopressor has been started. You wonder whether she would benefit from low-dose steroids?
Search Strategy:
Medline: 2002 to August 2004 using the Ovid interface
Search Details:
[(exp SEPSIS/ or exp SEPSIS SYNDROME/ or sepsis.mp.) OR (exp Shock, Septic/ or septic shock.mp.)] AND [(exp STEROIDS/ or steroids.mp.) OR (exp Adrenal Cortex Hormones/ or corticosteroids.mp.) OR (exp GLUCOCORTICOIDS/ or glucocorticoids.mp.)] limit to human
Outcome:
353 citations identified. By limiting this startegy to clinical trials and meta-analyses the citations were reduced to 33. Only 6 appeared relevant to the question. One was a meta-analysis (Minneci 2004). There were three relevant trials, one trial in ARDS, and one best evidence summary. A further meta-analysis (Annane 2004) not yet on Medline had previously been identified. As there were no trials not covered by the meta-analyses only these were reviewed.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis Annane D, Bellisant E, Bollaert PE, Briegel J, Keh D, Kupfer Y 2004 France | Meta-analysis | All cause mortality | Relative risk 0.80 (95% CI, 0.67 to 0.95, P=0.01) | ||
| ICU mortality | Relative risk 0.83 (95% CI, 0.70 to 0.97, P=0.02) | ||||
| Hospital mortality | Relative risk 0.83 (95% CI, 0.71 to 0.97, P=0.02) | ||||
| Shock reveral at day 7 | Relative risk 1.60 (95% CI, 1.27 to 2.03, P<0.0001) | ||||
| Shock reversal at day 28 | Relative risk 1.26 (95% CI, 1.04 to 1.52, P=0.02) | ||||
| Meta-analysis: the effects of steroids on survival and shock during sepsis depends on dose Minneci PC, Deans KJ, Banks SM, Eichacker PQ, Natanson C 2004 USA | Meta-analysis | Survival | Relative risk 1.23 (95% CI, 1.01 to 1.50, P=0.036) | Only 4 of the 5 studies presented data for shock reversal | |
| Shock reversal | Relative risk 1.71 (95% CI, 1.29 to 2.26, P<0.001) |
Author Commentary:
Both meta-analyses identified the same 5 randomised controlled trials of low dose steroids in severe sepsis and septic shock. These included 463 patients, however nearly 70% were from one study by Annane et al (2002).
Only 3 studies included data on responses to corticotropin stimulation testing.
Only 3 studies included data on responses to corticotropin stimulation testing.
Bottom Line:
Patients with severe sepsis or septic shock should be given low dose steroids (200-300 mg hydrocortisone) for 5-7 days.
References:
- Annane D, Bellisant E, Bollaert PE, Briegel J, Keh D, Kupfer Y. Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis
- Minneci PC, Deans KJ, Banks SM, Eichacker PQ, Natanson C. Meta-analysis: the effects of steroids on survival and shock during sepsis depends on dose