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ADRENAL: Difference between revisions
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Multiple RCTs have investigated the potential role for steroid therapy in patients with septic shock. The [[Annane Trial]] in 2002 with 299 patients demonstrated a short-term mortality benefit with IV hydrocortisone and fludrocortisone among patients with evidence of adrenal insufficiency on ACTH stimulation testing. [[CORTICUS]] with 499 patients in 2008 investigated hydrocortisone in patients with and without adrenal insufficiency and found a faster reversal of shock but no benefit in either subgroup with suggestion of increased infection rates in patients receiving hydrocortisone. [[HYPRESS]] in 2016 with 380 patients showed no difference in mortality but showed decrease time to reversal of shock. | Multiple RCTs have investigated the potential role for steroid therapy in patients with septic shock. The [[Annane Trial]] in 2002 with 299 patients demonstrated a short-term mortality benefit with IV hydrocortisone and fludrocortisone among patients with evidence of adrenal insufficiency on ACTH stimulation testing. [[CORTICUS]] with 499 patients in 2008 investigated hydrocortisone in patients with and without adrenal insufficiency and found a faster reversal of shock but no benefit in either subgroup with suggestion of increased infection rates in patients receiving hydrocortisone. [[HYPRESS]] in 2016 with 380 patients showed no difference in mortality but showed decrease time to reversal of shock. | ||
The | The '''AD'''junctive corticosteroid t'''RE'''atment i'''N''' critic'''A'''lly il'''L''' published in 2018 randomized patients with septic shock (ADRENAL) Trial included 3800 patients from 69 international sites, mostly in Australia. Patients were randomized if they were requiring vasopressor support for more than 4 hours and mechanical ventilation. There was no difference at the primary outcome of death from any cause at 90 days, nor were any difference found in any of the six sub-groups. The hydrocortisone group had faster time to reversal of shock, shorter time to discharge from the ICU, time to extubation, and decreased number of blood transfusion. The last of which was hypothesis generating. | ||
The 2016 Surviving Sepsis Campaign severe sepsis and septic shock<ref>[http://journals.lww.com/ccmjournal/Abstract/publishahead/Surviving_Sepsis_Campaign___International.96723.aspx Rhodes A, et al. "Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016." ''Critical Care Medicine.'' 2017;45(3)1-67.]</ref> suggests using IV hydrocortisone if hemodynamics cannot be stabilized using fluids and vasopressors. This recommendation was made before the release of the large ADRENAL trial and may lead to re-evaluation of this recommendation. This trial likely puts to rest steroids for all-comers in sepsis but did settle if steroids would be beneficial in patients that are non-responders to initial fluid resuscitation and vasopressor administration. | The 2016 Surviving Sepsis Campaign severe sepsis and septic shock<ref>[http://journals.lww.com/ccmjournal/Abstract/publishahead/Surviving_Sepsis_Campaign___International.96723.aspx Rhodes A, et al. "Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016." ''Critical Care Medicine.'' 2017;45(3)1-67.]</ref> suggests using IV hydrocortisone if hemodynamics cannot be stabilized using fluids and vasopressors. This recommendation was made before the release of the large ADRENAL trial and may lead to re-evaluation of this recommendation. This trial likely puts to rest steroids for all-comers in sepsis but did settle if steroids would be beneficial in patients that are non-responders to initial fluid resuscitation and vasopressor administration. | ||