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Steroids for Septic Shock^*

Back From the Dead? (Con)

^* From the Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Medical College of Virginia Hospitals, Richmond, VA.

Correspondence to: Curtis N. Sessler, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Medical College of Virginia at Virginia Commonwealth University, Box 980050, Richmond, VA 23298; e-mail: csessler{at}hsc.vcu.edu

The role of corticosteroid therapy in the management of septic shock has been debated for half a century. Results from large, well-designed, randomized clinical trials demonstrate no benefit, and perhaps harm, associated with short duration, high-dose methylprednisolone or dexamethasone administered at the onset of septic shock. Based on evidence of "relative adrenal insufficiency" and steroid-responsive adrenergic receptor desensitization in sepsis, administration of modest doses (200 to 300 mg/d) of hydrocortisone for 1 to 3 weeks has been investigated. A multicenter, placebo-controlled clinical trial demonstrated improved survival rates and faster cessation of vasopressors among patients with septic shock who have a poor response to corticotropin injection, consistent with relative adrenal insufficiency. However, concerns regarding a trend for higher mortality among corticotropin responders and the possibility that patients with true adrenal insufficiency may have been enrolled in this placebo-controlled trial, potentially skewing results, should be considered.

Key Words: adrenal insufficiency • adrenergic receptor responsiveness • corticosteroid therapy • hydrocortisone • septic shock • supraphysiologic doses • vasopressor support

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