Refractory shock The role of steroids

The evidence for the use of steroids in the treatment of severe sepsis has gone full circle in the last 20 years, with recent interest focusing on low doses. In patients with severe sepsis there are complex effects on the hypothalamic-pituitary-adrenal axis. On the one hand there is stimulation of the axis and loss of negative feedback control, which usually leads to high adrenocorticotrope hormone (ACTH) and cortisol levels. On the other hand various mediators cause adrenal suppression and glucocorticoid resistance. With time ACTH levels may fall due to inhibition or pituitary depletion - this leads to relative adrenal suppression. Recent studies have shown that patients with sepsis who are dependent on vasoactive drugs may benefit from stress doses of hydrocortisone (50-100 mg intravenously 4 times a day for 7 days). A proportion of these have relative adrenal insufficiency as defined by the short synacthen test and these patients have the greatest benefit in terms of mortality. Whilst a proportion of patients may benefit, steroids are not a routine treatment in sepsis.

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