REVERSAL OF LATE SEPTIC SHOCK WITH SUPRAPHYSIOLOGICAL DOSES OF HYDROCORTISONE

Objectives: Preliminary studies have suggested that low doses of corti costeroids might rapidly improve hemodynamics in late septic shock tre ated with catecholamines, We examined the effect of hydrocortisone on shock reversal, hemodynamics, and survival in this particular setting. Design: Prospective, randomized, double-blind, placebo-controlled stu dy. Setting: Two intensive care units of a University hospital. Patien ts: Forty one patients with septic shock requiring catecholamine for > 48 hrs. Interventions: Patients were randomly assigned either hydro co rtisone (100 mg iv three times daily for 5 days) or matching placebo. Measurements and Main Results: Reversal of shock was defined by a stab le systolic arterial pressure (>90 mm Hg) for greater than or equal to 24 hrs without catecholamine or fluid infusion, Of the 22 hydrocortis one-treated patients and 19 placebo-treated patients, 15 (68%) and 4 ( 21%) achieved 7-day shock reversal, respectively, a difference of 47% (95% confidence interval 17% to 77%; p=.007). Serial invasive hemodyna mic measurements for 5 days did not show significant differences betwe en both groups. At 28 day follow up, reversal of shock was higher in t he hydrocortisone group (p=.005). Crude 28-day mortality was 7 (32%) o f 22 treated patients and 12 (63%) of 19 placebo patients, a differenc e of 31% (95% confidence interval 1% to 61%; p=.091). Shock reversal w ithin 7 days after the onset of corticosteroid therapy was a very stro ng predictor of survival. There were no significant differences in out come in responders and nonresponders to a short corticotropin test, Th e respective rates of gastrointestinal bleeding and secondary infectio ns did not differ between both groups. Conclusions: Administration of modest doses of hydrocortisone in the setting of pressor-dependent sep tic shock for a mean of >96 hrs resulted in a significant improvement in hemodynamics and a beneficial effect on survival. These beneficial effects do not appear related to adrenocortical insufficiency.