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57-year-old male admitted to the MICU with severe CAP complicated by severe septic shock for the last 28 hrs despite proper fluid resuscitation and Norepinep 0.9 mcg/kg/hr his MAP 60-63 mmHg #septic @CHESTCritCare
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock Pt has sepsis and low MAP despite adequate fluid resuscitation, require vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg and have a lactate >2 mmol/L
After PAMPS and DAMPS active the cascade of anti-inflammatory and pro-inflammatory body response this can reach the desregulated response
Excess of pro-inflammatory mediators, complement system 
vasodilation emigration of inflam cells tissue ischemia, cythopathic injury, mitochondrial dysfunction, impairment of HPA axis, and corticosteroids resistance.
vasodilation emigration of inflam cells tissue ischemia, cythopathic injury, mitochondrial dysfunction, impairment of HPA axis, and corticosteroids resistance.
Mortality of Septic shock > 40%
Management of Septic shock
- early and proper antibiotic
- Proper fluid resuscitation
- source control
- Organs support
- hemodynamic support with vasopressors to keep decent perfusion.
- corticosteroids
- early and proper antibiotic
- Proper fluid resuscitation
- source control
- Organs support
- hemodynamic support with vasopressors to keep decent perfusion.
- corticosteroids
Corticosteroids in septic shock
I don’t want to start with the few RCT < 2002 let us start from 2002
I don’t want to start with the few RCT < 2002 let us start from 2002
Annane Trial: 2002
• Randomized, prospective, double blind
• 300 septic shock pts
• intervention; Pt randomized to either hydrocortisone + Fludrocortison or placebo
• 28 days mortality
10% compared to the placebo.
• Median time to withdrawal of vasopressors 7 vs 10 days
• Randomized, prospective, double blind
• 300 septic shock pts
• intervention; Pt randomized to either hydrocortisone + Fludrocortison or placebo
• 28 days mortality
10% compared to the placebo. • Median time to withdrawal of vasopressors 7 vs 10 days
CORTICUS trial 2008
• Randomized, prospective, double blind
• 499 septic shock pts
• intervention; Pt randomized to either hydrocortisone or placebo
• No 28 days mortality difference
• Reversal of shock 76% vs. 70.4% (P=0.41)
• Time to reversal of shock
3.3 vs. 5.8 days
• Randomized, prospective, double blind
• 499 septic shock pts
• intervention; Pt randomized to either hydrocortisone or placebo
• No 28 days mortality difference
• Reversal of shock 76% vs. 70.4% (P=0.41)
• Time to reversal of shock
3.3 vs. 5.8 days
APROCCHS trial 2018
• Randomized, prospective, double blind
• 1241 septic shock pts
• intervention; Pt randomized to either hydrocortisone + Fludro or placebo
• 90 days mortality 6%
• Quicker Time to shock reversal
• Randomized, prospective, double blind
• 1241 septic shock pts
• intervention; Pt randomized to either hydrocortisone + Fludro or placebo
• 90 days mortality
6% • Quicker Time to shock reversal
ADRENAL trial; 2018
• Randomized, prospective, double blind
• 3713 septic shock pts
• intervention; Pt randomized to either hydrocortisone or placebo
• No 90 days mortality difference
• Quicker Time to shock reversal
• Randomized, prospective, double blind
• 3713 septic shock pts
• intervention; Pt randomized to either hydrocortisone or placebo
• No 90 days mortality difference
• Quicker Time to shock reversal
Let’s not talk about HYPRESS (2016) because it was for sepsis and septic shock
It’s obvious the data shows conflicting evidence if corticosteroid have mortality benefits, however, it more obvious that all data agreed with that corticosteroids time to shock reversal 
To be fair there is a side effect from using steroids for a short period (Hypercalcemia)
To be fair there is a side effect from using steroids for a short period (Hypercalcemia)
No let’s ask the same question again
57-year-old male admitted to the MICU with severe CAP complicated by severe septic shock for the last 28 hrs despite proper fluid resuscitation and Norepinep 0.9 mcg/kg/hr his MAP 60-63 mmHg
57-year-old male admitted to the MICU with severe CAP complicated by severe septic shock for the last 28 hrs despite proper fluid resuscitation and Norepinep 0.9 mcg/kg/hr his MAP 60-63 mmHg
