Corticosteroids for Treating Sepsis in Children and Adults

What are the effects of corticosteroids on mortality among children and adults with sepsis?Sepsis is a life-threatening condition that can cause multiorgan dysfunction, and it has a substantial impact on health care internationally. Sepsis and septic shock affect millions of people around the world and result in very high mortality rates.1 The World Health Organization estimates that more than 30 million people develop sepsis each year, with an estimated mortality rate of 6 million.2 According to the Centers for Disease Control and Prevention, at least 1.7 million patients develop sepsis each year in the United States, and of those, approximately 270 000 die as a result.3An abnormal systemic response to infection causes sepsis; septic shock occurs in a subset of patients with sepsis and is associated with a higher risk of mortality.1 Success in treating sepsis requires early intervention and appropriate management with antibiotics, intravenous fluids, and vasopressor support that often requires admission to an intensive care unit (ICU). Because an internal response to infection causes sepsis, it is hypothesized that treatments that reduce the inflammatory and immune responses, such as corticosteroids, can improve outcomes.1Although the rationale seems strong for the use of corticosteroids, clinical data collected internationally remain inconsistent, which has led to a wide variety of treatment regimens. Therefore, this systematic review examined best available evidence regarding the effects of corticosteroids on mortality in patients with sepsis.4This summary is based on an updated Cochrane systematic review by Annane et al4 that included individual patient data from 61 randomized controlled trials including a total of 12 192 hospitalized patients with sepsis. Of these trials, 2 included both adults and children, 6 included only children, and the remaining 53 trials included only adults. They investigated 1 primary outcome: 28-day mortality. The secondary outcomes included:Annane et al4 independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion.They used risk ratios (RRs) with 95% CIs for dichotomous outcomes and mean differences for continuous outcomes as measures of treatment effect between various comparisons and outcomes. They used the internationally approved Grading of Recommendations Assessment, Development and Evaluation approach to determine the certainty of evidence—high, moderate, low, or very low—for each outcome:This systematic review found that, among patients with sepsis, moderate-certainty evidence indicated that corticosteroids likely reduce 28-day and in-hospital mortality. Corticosteroids also reduce ICU length of stay and greatly reduce hospital length of stay. Corticosteroids were, however, shown to increase the risk of muscle weakness and hypernatremia, and were likely to increase the risk of hyperglycemia.Although this review does support a benefit in using corticosteroids as part of the regimen for treating sepsis, some adverse events should be monitored. Nurses and health care teams should consider evaluating such a benefit before using corticosteroids to treat patients with sepsis. The results of this review and of future work will continue to help guide the care of these patients, including the dosing of corticosteroids (ie, continuous vs intermittent bolus), long-course and low-dose regimens, and long-term neuromuscular effects.As nurses caring for patients who are critically ill, advocating for the most appropriate evidence-based treatment remains an important piece of our role. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is most appropriate to implement in our individual context.