Low-dose corticosteroids in septic shock: Has the pendulum shifted?

The utility of low-dose corticosteroids in septic shock is reviewed. Low-dose corticosteroids are suggested as treatment for septic shock patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy. However, the risks and benefits of corticosteroids are unclear in this patient population. Previous multicenter trials have yielded conflicting results on the survival benefits of corticosteroids. The recently published Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) and Activated Protein C and Corticosteroids for Human Septic Shock (APROCCHSS) trials provide valuable but opposing insight into this ongoing debate. Discordant findings related to mortality in these trials are likely related to differences in study design, corticosteroid regimen, and baseline characteristics among enrolled patients. The utility of adding fludrocortisone to hydrocortisone compared with using hydrocortisone alone is unclear. There does not appear to be an advantage to administering corticosteroids as a continuous infusion to reduce the rate of hyperglycemia or providing a taper to prevent rebound hypotension. The mortality benefit of corticosteroids appears to be greatest in septic shock patients with high vasopressor requirements, evidence of multiorgan failure, and primary lung infections. Corticosteroids consistently lead to a faster reversal of shock and may shorten the duration of mechanical ventilation. Corticosteroids do not seem to increase the risk of superinfection at low doses but frequently lead to a higher frequency of hyperglycemia. We recommend the administration of corticosteroids to septic shock patients with escalating doses of vasopressors and evidence of multiorgan dysfunction.