What are the guidelines for corticosteroid therapy in the treatment of sepsis/septic shock?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

The 2012 Surviving Sepsis Campaign guidelines emphasize that steroids should not be administered to patients with septic shock unless hemodynamic stability cannot be achieved with fluid resuscitation and vasopressor agents. [11] In addition, these guidelines [11, 60] and those of the ACCCM [65] recommend the following:

  • Do not use the ACTH stimulation test to identify the subset of adult patients with septic shock (or ARDS) who should receive hydrocortisone [11, 60, 65]

  • Do not administer dexamethasone when hydrocortisone is available; fludrocortisone is optional if hydrocortisone is used, but when hydrocortisone is not available and the substituted steroid does not have significant mineralocorticoid activity, consider daily administration of oral fludrocortisone (50 µg once daily) [11, 60]

The ACCCM also has the following treatment recommendations [65] :

  • For patients with septic shock, administer hydrocortisone 200 mg/day IV in 4 divided doses or as a 100-mg bolus followed by continuous infusion at 10 mg/hr (240 mg/d); in patients with early severe ARDS, the optimal initial treatment regimen is continuous infusion of methylprednisolone 1 mg/kg/day

  • Although the optimal treatment period for corticosteroids in patients with septic shock and early ARDS remains to be determined, a regimen of 7 days or longer should be used in patients with septic shock—provided that signs of sepsis or shock do not recur—before tapering, and a regimen of 14 days or longer should be used in patients with early ARDS before tapering

  • Do not use dexamethasone therapy for septic shock or ARDS

The following key points summarize use of corticosteroids in septic shock:

  • Older, traditional trials of corticosteroids in sepsis were unsuccessful, probably because of high dosages and poor patient selection

  • More recent trials with low-dose (physiologic) dosages in select patient populations (those with vasopressor dependence and, possibly, relative adrenal insufficiency) may have resulted in improved outcome

  • Corticosteroids (hydrocortisone) should be considered only for patients with vasopressor-dependent septic shock [65] ; wean steroid therapy when vasopressor therapy is no longer needed [11, 60]

  • Consider moderate-dose corticosteroids in the management of patients with early severe ARDS (arterial oxygen tension [PaO2]/fraction of inspired oxygen [FIO2] < 200), as well as before day 14 in patients with unresolving ARDS [65] ; investigators still need to determine what role corticosteroid treatment may have in less severe ARDS (PaO2/FIO2 >200) [65]

  • A cortisol stimulation test may be performed to identify patients with relative adrenal insufficiency, defined as failure to increase levels by more than 9 µg/dL

  • Do not administer corticosteroids to treat sepsis when shock is not present [11, 60]

  • Maintenance steroid therapy or stress-dose steroids may be continued as needed on the basis of the patient’s endocrine or corticosteroid-administration history [11, 60]


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