Your guide to steroids in septic shock


    Your guide to steroids in septic shock

    Ok, so you know there is controversy in the use of steroids in septic shock, but what does the data actually support in terms of when you should and should not use them — here is a guide!

    Don’t want to read more? Here is the jist: Steroids (hydrocortisone <400mg/day) may reduce time in shock for patients with severe septic shock (sBP<90 after 1 hr of pressors + IVF). No evidence for mortality benefit. No evidence in other septic shock patients.

    Why might steroids work? In the setting of critical illness, the hypothalamus secrets CRH (cortisol releasing hormone) to increase cortisol and maintain a sympathetic response. Several factors influence a positive feedback loop to maintain a high level of cortisol. There is reduced cortisol breakdown, reduced excretion, increased receptor affinity and diminished protein binding. In the setting of relative adrenal insufficiency, the body cannot meet the demands for cortisol, which can result in refractory shock. Therefore, in some patients, steroids may help refractory shock.

    Is there a mortality benefit? No. The majority of studies do not show a mortality benefit to steroids in septic shock.

    Is there any benefit? In patients with severe septic shock (defined as continued hemodynamic instability (sBP<90 after adequate fluid resuscitation and 1 hour of pressors) steroids could decrease the duration of shock.

    What are the risks of steroids? Although there is fear steroids could worsen bacterial superinfection, there is no data that supports this. Steroids do cause hyperglycemia.

    Is there a way to test for adrenal insufficiency? Long story short: No. Testing is not reliable in critically ill patients.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • It’s Freezing!

      You are at elmhurst in the cardiac room. It is FREEZING outside. The triage nurse tells you there is a frequent flier in triage, EMS found him sleeping on the street with +AOB. He isRead more

    • pediatric blood transfusion

      So you’re in peds and your patient is anemic. You need to transfuse, but you are confused. How much blood do you give? How fast do you give it? How much: The volume of bloodRead more

    • Spontaneous Pneumomediastinum

      Your patient is a 24 yo M with chest pain.  It is pleuritic. He has normal vitals and you’re not too concerned. You get a CXR and you see the result in this post. HeRead more

    • In flight emergencies and when to land the plane

      You are on a flight, halfway across the Atlantic Ocean at the start of a much needed vacation, binge watching that new show everyone has been talking about but you’ve never had time to see. Read more

    • PE risk stratification: which tool is best?

        Your patient with a newly diagnosed PE hates hospitals.  He or she agrees to defer to your judgement about admission versus discharge home, but makes it clear they would prefer to go home ifRead more

    • Proper cane use

      We give out canes like they’re candy.  But are we doing a good job adjusting the cane and teaching patients how to use them?  Canes that are not the right height for your patient orRead more

    • Do antivirals or steroids help make shingles better?

      A patient comes to the emergency department reporting a few days of excruciating pain in a band around his right chest.  Today, he developed vesicles over the same area which prompted him to come in.Read more

    • Double Sequence No-no???

        You are the leader of the code team.  Your patient is in refractory VF after multiple rounds of shocks and drugs.  You’ve tried repositioning the pads into an anterior-posterior position.  Looking around, you askRead more