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.