Stress dose steroids

Question Hydrocortisone in patients with septic shock? ADRENAL Trial, Corticus

ADRENAL Trial - Adjunctive Glucocorticoid Therapy in Patients with Septic Shock

3800 patients

One group stress dose 200 hydrcort IV infusion over 7 days versus placebo

Primary outcome Mortality OR 0.95 CI 0.82 – 1.1 p = 0.5 not stat sig

Secondary outcome 28 day mortality no difference

Resolution of shock Median 3 days IQR 2 -5, vs 4 days IQR 2 to 9 HR 1.32, 95% CI 1.23 to 1.41; P<0.001

Got over shock faster, less pressors, central line for less time, less labs

No difference in recurrence of shock

ICU stay SDS spent less time in ICU than placebo

Hospital length of stay: no difference

Duration of mechanical ventilation duration: SDS Median 6 days IQR 3 to 18 vs 7 days IQR 3 to 24, HR 1.13 95% CI 1.05 to 1.22 P<0.001

Less mechanical ventilation time on patients with stress dose steroids

Extubated reintubation rates are not higher with SDS, does stress dose steroids make diaphragm weaker, probably not

Infection risk – SDS increase bacteremia / fungemia? False not statistically significance

37% vs 41.7%; OR 0.82 95% CI 0.72 to 0.94; P = 0.004, less blood transfusions in those with stress dose steroids

People with refractory sepsis have tendency to get more volume, IV fluids, make numbers pretty. If you don’t need more fluid because sepsis is resolving faster, not going to hemodilute don’t need blood transfusions, septic shock sooner, no constant vampire bloodwork in patients with septic shock, abgs for ventilator titration, BMP, mg, phos. If less test less blood need less blood transfusions

Renal replacement therapy no difference in placebo versus stress dose steroids

Adrenal, Corticus

 

6 to 12 hr those that got stress dose steroids statistically significant

 

90 day mortality no difference

Stress dose steroids, more rapid improvement in shock less days in ICU, less days on ventilator

No difference recurrence of shock, no difference in need for CRRT, no difference in bacteremia and fungemia

Septic shock, fluids and antibiotics, optimal volume status, bedside echo and IVC, titrate up levophed for particular map, achieve all map, climbing over 12 to 15 mcg, put in order for vasopressin and SDS

Don’t check cortisol level or ACTH stim test

Corticus - Hydrocortisone Therapy for Patients with Septic Shock 800