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GENERAL MEDICINE

Role of Corticosteroids in Septic Shock

Critical Care Specialist/Surgical Team Leader, Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada

Randy S Wax, MD FRCPC

Critical Care Physician, Education Director, Department of Medicine, Mount Sinai Hospital; Faculty of Medicine, University of Toronto, Toronto

Reprints: Lisa D Burry BScPharm PharmD FCCP, Department of Pharmacy, Mount Sinai Hospital, 600 University Ave., Toronto, Ontario M5G 1X5, Canada, fax 416/586-8353, lburry{at}mtsinai.on.ca

OBJECTIVE: To highlight the role of relative adrenal insufficiency in the outcome of critically ill patients with sepsis and systematically review the literature regarding the use of corticosteroids for management of severe sepsis/septic shock.

DATA SOURCES: A computerized search of MEDLINE, EMBASE, and the Cochrane Database was undertaken from 1966 to March 2003 using the search terms intensive care unit, critical care, corticosteroids, glucocorticoids, adrenal insufficiency, sepsis, and septic shock. Bibliographies of all articles retrieved were searched for relevant articles not identified by the computerized search.

DATA EXTRACTION/SYNTHESIS: Six trials were identified after publication of the meta-analyses (1995), with a total of 505 patients. The results of these trials in septic shock suggest that low-dose corticosteroids can reduce vasopressor requirements and hasten reversal of shock. Some of these trials suggested a possible mortality benefit from therapy, and no trial demonstrated an increase in mortality or significant adverse effects. The benefit of this therapy may depend on the presence of relative adrenal insufficiency, as identified by the adrenocorticotropic hormone stimulation test.

CONCLUSIONS: Low-dose corticosteroids should be administered to patients with septic shock empirically, but should be discontinued if relative adrenal insufficiency is not confirmed.

Key Words: adrenal insufficiency, corticosteroids, sepsis, septic shock

Published Online, January 23, 2004. www.theannals.com, DOI 10.1345/aph.1C435

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