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Early Initiation of Low-Dose Corticosteroid Therapy in the Management of Septic Shock: A Retrospective Observational Study
Park H, Suh G, Song J, et al. Critical Care 2012. 16:R3.
Study Question: Does early initiation of low-dose steroid therapy affect mortality in patients with septic shock?
Study Description: In this retrospective review, patients who received low-dose steroid therapy for septic shock were analyzed. Patients were excluded if they: were < 18 years old; had received systemic corticosteroids within the past 3 months; were immunocompromised; or had undergone stem cell or solid organ transplantations. All patients received early goal-directed therapy according to a protocol adapted from the original report from Rivers et al. When a patient remained hypotensive after at least 1 h of resuscitation with fluids and vasopressor, hydrocortisone was started at 50 mg IV q 6 h x 5 d, then 50 mg IV q 12 h x 3 d, then 50 mg IV daily x 3 d. The primary outcome was 28-day mortality and secondary outcomes were reversal of shock, ICU mortality, in-hospital mortality, and duration of ICU and hospital stay.
Results: In 178 patients, 28-day mortality was 44%. Reversal of shock was achieved in 67% after a median time of 35 h of corticosteroid therapy. ICU and in-hospital mortality rates were 43% and 58%, respectively. Median length of ICU and hospital stay were 6 (range 3-11) days and 16 (7-31) days, respectively. Non-survivors had significantly higher median Simplified Acute Physiology Score (SAPS) 3 and Sequential Organ Failure Assessment (SOFA) score, vasopressor requirements, and need for mechanical ventilation and renal replacement therapy. The median time to initiation of corticosteroid therapy was significantly shorter in survivors than non-survivors (6.5 vs. 10.4 hours, p = 0.0135). Time to initiation of low-dose corticosteroid therapy was significantly associated with 28-day mortality (adjusted OR 1.025, 95% CI 1.007-1.044). Patients were categorized as early (≤ 6 h) or late (> 6 h) therapy groups. The proportion of patients who showed reversal of shock was similar in both groups. ICU mortality (32% vs. 49%) and 28-day mortality (32% vs. 51%) were improved in the early-therapy group than in the late-therapy group (p = 0.0243 and p = 0.0132, respectively).
Conclusion(s): The authors conclude there is a significant association between early initiation of low-dose corticosteroid therapy and decreased mortality in patients with septic shock.
Perspective: Time to administration of corticosteroids has been proposed as a possible explanation for the difference outcomes seen in the past by Annane et al and in the CORTICUS trial. The interesting results of this study need to be confirmed in a randomized controlled clinical trial.