What Is the Role of Steroids in Septic Shock?

Systematic inflammatory response syndrome (SIRS) is defined by the presence of at least two of the following: fever or hypothermia; leukocytosis, leukopenia, or bandemia; heart rate >90 bpm; or tachypnea or hypocapnia.

Key Points

  • Low-dose hydrocortisone should be added to the treatment regimen for patients with septic shock that is unresponsive to IV fluids and vasopressor therapy. The recommended dose is 50 mg IV every six hours, or 100 mg IV bolus followed by an infusion of 10 mg/hour for seven days.
  • Once hemodynamically stable, hydrocortisone should then be tapered over a few days (to avoid rebound hypotension).
  • An ACTH stimulation test prior to administering steroids in sepsis is not recommended.
  • There is no role for steroids in sepsis in the absence of shock, nor is there a role for high-dose steroids in sepsis.

The Case

An 81-year-old woman with diabetes mellitus presents with a three-day history of fever, chills, left-side flank pain, and dysuria. Her blood pressure upon presentation is 75/45 mm/Hg, her heart rate is 120 beats per minute, and she has a temperature of 103.1°`F and a respiratory rate of 22 breaths/minute. On physical examination, she is an ill-appearing elderly woman, with dry oral mucosa and left costo-vertebral angle tenderness. Lab work shows leukocytosis of 18,000 mg/dL with 88% polymorphonuclear leukocyte (PMN), the urine analysis is consistent with a urinary tract infection, and a chemistry panel reveals elevated BUN and creatinine levels of 52 mg/dL and 2.4 mg/dL, respectively. In the emergency department, she is given a bolus of 2 liters normal saline, but her blood pressure remains 78/49 mm/Hg. She is then started on broad-spectrum antibiotics and a norepinephrine drip, and is admitted to the ICU.

What role would steroids add to her management?

Background

Sepsis is the clinical syndrome defined by the presence of systemic inflammatory response syndrome (SIRS) in the setting of an infection. SIRS is defined by the presence of at least two of the following: fever or hypothermia; leukocytosis, leukopenia, or bandemia; heart rate >90 bpm; or tachypnea or hypocapnia.

When acute organ dysfunction, such as acute renal failure, altered mental status, or acute lung injury (hypoxemia), is present, sepsis is classified as severe.

Septic shock is a state of sepsis associated with acute circulatory collapse characterized by persistent arterial hypotension (defined as a systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, or a reduction in systolic blood pressure of >40 mmHg from baseline) despite fluid resuscitation attempts.1

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