1. Steroids in Sepsis

2. What do we want steroids to do?
Improve Mortality
Decrease Pressors
Decrease Ventilator Time
Decrease ICU LOS

3. Why do we think steroids may help?
Relative adrenal insufficiency
What do glucocorticoids do during stress?

4. The Cosyntropin Stim Test

5. Empiric Treatment of AI
Dexamethasone 2mg IV bolus
Hydrocortisone 50mg IV q6h

6. How to Interpret a Stim Test

7. Randomized to steroid supplementation or placebo
Annane – Effect of Treatment with Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock (2002)
Randomized to steroid supplementation or placebo
Determined to be “responders” or “non-responders” by cosyntropin test
300 patients
Majority on dopamine as their pressor
Relatively sick patients compared to other studies
Used fludrocortisone (for primary adrenal insufficiency) in addition to hydrocortisone
No baseline value (15) used
Mortality benefit even when controlled for etomidate

10. What do we want steroids to do?
Improve Mortality (YES – in responders)
Decrease Pressors (YES – in responders)

11. Randomized to steroid supplementation or placebo
Sprung and Annane – Hydrocortisone Therapy for Patients with Septic Shock (2008)
Randomized to steroid supplementation or placebo
Determined to be “responders” or “non-responders” by cosyntropin test
499 patients
Hydrocortisone only
Fludrocortisone felt to be unnecessary given hydrocortisone has a mineralocorticoid effect and there is unpredictable absorption of po med
Patient not as sick at baseline as in prior Annane study
More people on norepi than dopamine
Enrolled patients up to 72 hours after refractory septic shock developed (compared to 8 hours in the Annane study)

12. Mortality
Not significant

13. Time to reversal of shock

15. What do steroids really do?
Improve Mortality (?)
Decrease Pressors (?)
Decrease Ventilator Time (?)
Decrease ICU LOS (?)