Early morning pre-rounds - Data gathering, evaluating status changes, interventions done overnight, today's exam - changed /unchanged.





While you diligently go room to room- there are 2 Pt's in adjoining rooms with the diagnosis of Septic Shock.As you sift through the data, you notice - one of them is on steroids while the other is not. Everything else looks the same - antibiotic combination, multiple vasopressor's , ventilator setting's.Did someone miss something.You question the Nurse who has both Pt's. She shrugs & says- 'Fellow A who admitted the 1st Pt is a Steroid believer'; while 'Fellow B who admitted the 2nd Pt overnight avoids them'.





Confused you raise the Issue while presenting the Pt's - Both Fellows are present, all of a sudden the Rounds stop & terms like ' CIRCI, Stim Test' get thrown about. While the 2 Fellows go at each other with Swords drawn, the Attending smiles - waves everyone to the Power Point Room (God Bless Microsoft & Office 360!).





Turns out - ICU is a place of Relative Deficiencies (Nurses, Resident's - all feel they need more staffing).Critical illness seems to result in 'Critical illness Related Corticosteroid Insufficiency' = CIRCI.Seems like we need more than what's present in times of need.There is a test to see if supplementation is needed - 'ACTH Stimulation Test' fondly called the 'Stim Test'.However nobody can agree on what dose of ACTH to use. Sepsis leads to - 'Dysregulation of the Host Response' & Steroids are needed to attenuate this.They attenuate inflammation, improve SVR & Restore blood volume.Intensivist's for a change are split - 1/3 add steroids, 1/3 do not, while the other 1/3 depending on Sun position use it or abstain & are ambivalent.





Studies with Fancy Names?





ADRENAL Trial in NEJM March 1, 2018. A multicenter trial across 5 countries from 2013- 2017. 3800 Pt's with Septic Shock & on Mechanical Ventilation were randomized to Steroids (Hydrocortisone 200 mg/day) -1832 vs Placebo 1826. No difference was found in primary outcome of Mortality at 90 days ( 27.9% vs 28.8%) .Secondary Outcome however favored Steroid use - faster Shock resolution, early liberation from Ventilator & lower PRBC transfusion.





the trial did exclude Pt's who received Etomidate for Intubation - As you raise the Query - it seems that Power Point is for a different day.





APROCCHSS Trial in NEJM March 1st, 2018.Another multicenter trial (2008 - 2015), 1241 Pt's with Septic Shock on high dose vasopressor's for at least 6 hours, were Randomized to Hydrocorticone + Fludrocortisone (614) vs Placebo (627).

The initial randomization included a third group where activated protein C was used - that arm was stopped after the drug was withdrawn due to lack of efficacy (APROC needs to be removed from name!).

Primary outcome of Mortality at 90 days was significantly lower in Steroid arm (43% vs 49.1%; p=0.03). Secondary outcome were also better in the steroid arm (less time to ICU & Hospital Discharge, more vasopressor free days & Organ Failure free days.





So What now : 2 large trials slight difference, 1 shows mortality benefit while other none.Given this, in Septic Shock after proper resuscitation, if vasopressor need persists - just add steroids - (Hydrocortisone 50 mg every 6 hrs + Fludrocortisone 50 mcg PO once daily - no need to do an ACTH Stim Test). You may get a Mortality Benefit in the more sick Pt's; if not at the least - you get an early resolution of Shock, early discharge from ICU, maybe more ventilator free days. Side effect's like GI Bleed & Infection are not any worse with Steroid use.

No need to taper - just use for 7 days & control hyperglycemia with Insulin Use.





And 'NO' - you cannot prevent progression of Sepsis to Septic Shock with prophylactic steroids use- there is the HYPRESS Trial in JAMA 2016,316:1775-85 ,

that tried & failed.







