Comparison of shock reversal with high or low dose hydrocortisone in intensive care unit patients with septic shock: A retrospective cohort study

Association between various types of corticosteroids and mortality for severe community-acquired pneumonia in adults: a systematic review and network meta-analysis

OBJECTIVE

This study aims to conduct a systematic review and network meta-analysis to evaluate the efficacy and safety of specific corticosteroids, including but not limited to hydrocortisone, methylprednisolone, prednisolone, and dexamethasone, in the treatment of severe community-acquired pneumonia (SCAP). Efficacy will be assessed using specific outcomes, such as 30-day mortality and the requirement for mechanical ventilation. Safety evaluations will include adverse events like gastrointestinal bleeding and healthcare-associated infections. The study seeks to address the gaps identified in the latest guidelines regarding the optimal use of different corticosteroid types and to provide recommendations for clinical practice.

DATA SOURCES

This study conducted a comprehensive search of Medline, Embase, and the Cochrane Central Register of Controlled Trials, covering the period from inception until 22 June 2023. Randomized clinical trials for corticosteroid use among adults with SCAP were collected.

STUDY SELECTION

Two researchers independently assessed study eligibility based on titles and abstracts, with any disagreements resolved through discussion or consultation with a third researcher.

DATA EXTRACTION

Two researchers independently collected and clarified study details, with a third researcher adjudicating in case of disputes.

DATA SYNTHESIS

The data from 13 randomized clinical trials involving 2,495 patients, were analyzed using a random-effects model. Eleven trials were assessed as low risk, while two were assessed as high risk. Trials were rated as having low bias risk. Results, presented as risk ratios (RR) with a 95% confidence interval (CI), indicated that hydrocortisone outperformed prednisolone (RR 0.35; 95% CI 0.10-0.94), methylprednisolone (RR 0.41; 95% CI 0.15-0.89), and placebo (RR 0.35; 95% CI 0.16-0.59) in reducing 30-day mortality. A rankogram plot suggested that hydrocortisone had the highest probability of being the most effective treatment for this outcome within the analyzed group.

CONCLUSION

In this network meta-analysis, while hydrocortisone showed greater efficacy than prednisolone, methylprednisolone, and placebo in reducing 30-day mortality in patients with SCAP, further Randomized Controlled Trials (RCTs) are required to confirm these findings before drawing definitive conclusions.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=438389, identifier CRD42023438389.

Fludrocortisone Plus Hydrocortisone Versus Hydrocortisone Alone as Adjunctive Therapy in Septic Shock: A Retrospective Cohort Study

BACKGROUND

Trials evaluating hydrocortisone (HC) for septic shock are conflicting with all finding decreased time to shock reversal but few with mortality difference. Those with improved mortality included fludrocortisone (FC), but it is unknown if FC affected the outcome or is coincidental as there are no comparative data.

OBJECTIVE

The objective of this study was to determine the effectiveness and safety of FC + HC versus HC alone as adjunctive therapy in septic shock.

METHODS

A single-center, retrospective cohort study was conducted of medical intensive care unit (ICU) patients with septic shock refractory to fluids and vasopressors. Patients receiving FC + HC were compared with those receiving HC. Primary outcome was time to shock reversal. Secondary outcomes included in-hospital, 28-, and 90-day mortality; ICU and hospital length of stay (LOS); and safety.

RESULTS

There were 251 patients included (FC + HC, n = 114 vs HC, n = 137). There was no difference in time to shock reversal (65.2 vs 71 hours; P = 0.24). Cox proportional hazards model showed time to first corticosteroid dose, full-dose HC duration, and use of FC + HC were associated with shorter shock duration, while time to vasopressor therapy was not. However, in 2 multivariable models controlling for covariates, use of FC + HC was not an independent predictor of shock reversal at greater than 72 hours and in-hospital mortality. No differences were seen in hospital LOS or mortality. Hyperglycemia occurred more frequently with FC + HC (62.3% vs 45.6%; P = 0.01).

CONCLUSION AND RELEVANCE

FC + HC was not associated with shock reversal at greater than 72 hours or decreased in-hospital mortality. These data may be useful for determining corticosteroid regimen in patients with septic shock refractory to fluids and vasopressors. Future prospective, randomized studies are needed to further evaluate the role of FC in this patient population.

Effect of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock

DISCLAIMER

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PURPOSE

Several studies have shown hydrocortisone to be beneficial in the treatment of vasopressor-refractory septic shock, but there are minimal data evaluating the efficacy of this fixed dosing regimen in overweight and obese patients. The purpose of this study was to compare the effects of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock refractory to adequate fluid resuscitation and vasopressor administration.

METHODS

In this multicenter, retrospective study, we included adult patients with a confirmed or suspected diagnosis of septic shock who received hydrocortisone (200 mg/day). Patients were divided into 4 study groups based on admission body mass index (BMI; defined as BMI of <25 kg/m 2, 25-29.9 kg/m 2, 30-34.9 kg/m 2, and ≥35 kg/m 2). The primary outcomes analyzed were change in norepinephrine equivalent dose requirements and mean arterial pressure (MAP) at 6, 12, and 24 hours after initiating hydrocortisone.

RESULTS

Between October 1, 2017, and September 30, 2020, 431 patients were screened of whom 219 met inclusion criteria. Baseline characteristics were comparable among the groups. Mean vasopressor requirements (in ΀g/min) at 6, 12, and 24 hours were as follows: BMI of <25 kg/m 2:  28.8, 24.8, and 20; BMI of 25-29.9 kg/m 2: 34.1, 33.5, and 24.8; BMI of 30-34.9 kg/m 2: 29.5, 33.5, and 24.8; and BMI of ≥35≥kg/m 2: 32, 25.7 and, 21.2 (P = 0.75, 0.41, and 0.61, respectively). Mean MAP (in mm Hg) at 6, 12, and 24 hours was as follows: BMI of <25 kg/m 2:  73.5, 73.6, and 74; BMI of 25-29.9 kg/m 2: 71.6, 73.8, and 71.9; BMI of 30-34.9 kg/m 2: 72.2, 70, and 72.7; and BMI of ≥35 kg/m 2: 70.7, 73.5, and 71.4 (P = 0.56, 0.15, and 0.62, respectively).

CONCLUSION

BMI does not appear to impact the effects of fixed-dose hydrocortisone on vasopressor dose or blood pressure in patients with septic shock. Fixed-dose hydrocortisone should continue to be used for vasopressor-refractory septic shock in obese patients.