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Corticosteroids in Septic Shock: A Systematic Review and Network Meta-Analysis
Corticosteroids in Septic Shock: A Systematic Review and Network Meta-Analysis
Gibbison B, López-López JA, Higgins JPT, et al. Critical Care. 2017; 21: 78.
Study Question: Does any corticosteroid regimen provide superiority over others for adult patients with septic shock?
Study Description: This was a meta-analysis of randomized controlled trials in children and adults with sepsis recently used in a Cochrane Review. Studies were excluded if all data was pediatric, designed to evaluate respiratory function in acute respiratory distress syndrome or pneumonia, or cross-over in nature. Only data for adults (≥18 years of age) were included in the analyses.
Results: Thirty-three studies were eligible for review, of which 22 remained after exclusion and 1 partial study remained (child data removed). Most outcome measures had wide confidence intervals with a correlation that did not reach statistical significance. There was an association between bolus doses of methylprednisolone and increased risk of 28-day mortality over dexamethasone (OR 5.71, 95% CI 0.99-32.9; no p-value provided). Weak evidence supported a benefit of dexamethasone on 28-day mortality compared to placebo (OR 0.25, 95% CI 0.05-1.34; no p-value provided). Infusions of hydrocortisone increased risk of hospital mortality compared to boluses of dexamethasone (OR 0.47, 95% CI 0.15-1.46; no p-value provided). Boluses of dexamethasone increased superinfections compared to placebo and hydrocortisone (OR 2.78, 95% CI 0.73-10.6; no p-value provided). Hydrocortisone increased shock reversal compared to placebo, but the strongest evidence supported methylprednisolone for reversal compared to hydrocortisone (OR 0.37, 95% CI 0.19-0.72; no p-value provided). Only one study provided ICU mortality, showing benefit with methylprednisolone compared to placebo (OR 0.32, 95% CI 0.10-0.99; no p-value provided). When evaluating two studies, hydrocortisone may decrease ICU length of stay.
Conclusion(s): There is no conclusive evidence that one glucocorticoid regimen provides benefit over others in the management of septic shock.
Perspective: This study highlights the continued cloudiness regarding the optimal use of steroids for septic shock. Few studies in this evaluation directly compared treatment regimens. Corticosteroid regimen dosing, one of the controversies regarding this subject, was not evaluated. The inclusion of studies dating back 50 years almost limits interpretation of these results given advances in the management of septic shock and improvement in standards of care. Little can be taken from this study for application to modern-day practice and the ideal use of corticosteroid in patients with septic shock remains uncertain.