Later, she was weaned off norepinephrine and transferred out of the ICU. On hospital Day 7, a slow taper of her hydrocortisone initiated, and antibiotics were switched to oral levofloxacin. She was later discharged home in stable condition.
In patients with septic shock that is unresponsive to IV fluid resuscitation and vasopressors, the addition of low-dose corticosteroids is relatively safe and can improve rate of reversal of shock, reduce time to reversal of shock, decrease ICU length of stay, and potentially lower mortality.
Drs. Gandhi and Asudani are health science assistant professors of medicine in the Division of Hospital Medicine at the University of California at San Diego.
- Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med. 2003;29:530-538.
- Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310.
- Schumer W. Steroids in the treatment of clinical septic shock. Ann Surg. 1976;184:333-341.
- Sprung CL, Caralis PV, Marcial EH, et al. The effects of high-dose corticosteroids in patients with septic shock. A prospective, controlled study. N Engl J Med. 1984;311:1137-1143.
- The Veterans Administration Systemic Sepsis Cooperative Study Group. Effect of high-dose glucocorticoid therapy on mortality patients with clinical signs of systemic sepsis. N Engl J Med. 1987;317:659-665.
- Bone RC, Fisher CJ Jr, Clemmer TP, Slotman GJ, Metz CA, Balk RA. A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med. 1987;317:653-658.
- Lefering R, Neugebauer EA. Steroid controversy in sepsis and septic shock: a meta-analysis. Crit Care Med. 1995;23:1294-1303.
- Cronin L, Cook DJ, Cartlet J, et al. Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med. 1995;24:1430-1439.
- Hinshaw LB, Beller BK, Chang AC, et al. Corticosteroid/antibiotic treatment of adrenalectomized dogs challenged with lethal E. coli. Circ Shock. 1985;16:265-277.
- Rees DD, Cellek S, Palmer RM, Moncada S. Dexamethasone prevents the induction of NO synthase and the associated effects on vascular tone, an insight into endotoxin shock. BioChem BioPhy Res Comm. 1990;173:541-547.
- Axelrod L. Inhibition of prostacyclin production mediates permissive effect of glucocorticoids on vascular tone. Lancet. 1983;1:904-906.
- Annane D, Bellissant E, Sebille V, et al. Impaired pressor sensitivity to noradrenaline in septic shock patients with and without impaired adrenaline reserve. Br J Clin Pharmacol. 1991;46:589-597.
- DeKruif MD, Lemaire LL, Giebelen IA, et al. Prednisolone dose dependently influences inflammation and coagulation during human endotoxemia. J Immunol. 2007;178:1845-1851.
- Goldstein IM, Roos D, Weissman, G et al. Influence of corticosteroids on human polymorphonuclear leukocyte function in vitro. Inflammation. 1976;1:305-316.
- Briegel J, Kellerman W, Forst H, et al. Low-dose hydrocortisone infusion attenuates the SIRS. The Phospolipase A2 Study Group. Clin Invest. 1994;72:782-787.
- Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisones on mortality in patients with septic shock. JAMA. 2002;288:862-871.
- Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy in patients with septic shock. N Engl J Med. 2008;358:111-124.
- Annane D, Bellissant E, Bollaert P. Corticosteroids in the treatment of severe sepsis and septic shock in adults. A systematic review. JAMA. 2009;301:2362-2375.
- Dellinger DP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. 2008;34:17-60.
- Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008;36:1937-1949.
- Reincke M, Allolio B, Würth G, et al. The hypothalamic-pituitary-adrenal axis in critical illness: Response to dexamethasone and corticotropin-releasing hormone. J Clin Endocrinol Metab. 1993;77:151-156
- Keh D, Weber-Carstens S, Ahlers O. Adjunctive therapies in severe sepsis and septic shock: current place of steroids. Curr Infect Dis Rep. 2008;10:354-361.
- Keh D, Boehnke T, Weber-Cartens S, et al. Immunologic and hemodynamic effects of “low dose” hydrocortisone in septic shock: a double blind study, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med. 2003;167:512-520.
- Cronin L, Cook DJ, Carlet J, et al. Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med. 1995;23;1430-1439.
- Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids for treating severe sepsis and septic shock. Cochrane Database Syst Rev. 2004;1:CD002243.