I am fortunate to work in a hospital system that is very forward thinking. We have a phenomenal relationship with our intensivists, and I have been fortunate enough to have several discussions with them about how we are managing COVID-19 in our ICUs. For full transparency, I don’t work up in the ICU, but had the opportunity to discuss what we are doing in our ICUs with one of our intensivists (ECMO, steroids, Remdesivir, etc...). We are doing something different in San Antonio that I thought was worth discussing on this podcast that may be a feasible option for some institutions and some patients, but not all. If there is one thing this disease has taught me, that is one size does not fit all.
Background: There have now been several trials published on the use of steroids in sepsis. In 2002, we had the Annane Trial, with 299 patients showing mortality and shock reversal benefit in sepsis with hydrocortisone. Then in 2008 we had the CORTICUS trial, with 499 patients, which found a faster reversal of shock, but no benefit in mortality. Next the HYPRESS trial published in 2016 with 380 patients, with severe sepsis, not septic shock, showed no difference in mortality or time to reversal of shock. And finally the ADRENAL Trial published this year with 3800 patients show no difference in mortality, but a small benefit in reversal of shock. Due to these mixed results, many physicians have variable practice patterns with the use of steroids in sepsis/septic shock. Now, we have the APROCCHSS trial looking at hydrocortisone plus fludrocortisone for adults with septic shock (By the way the lead author is the same author that published the 2002 steroids in sepsis trial…Annane)....Read More
Background: A Cochrane review was published in 2015 evaluating 33 trials with 4,268 participants to evaluate the effects of corticosteroids on death at one month in patients with sepsis. In that meta-analysis the authors concluded that despite the overall low quality of evidence, corticosteroids still reduced mortality among patients with sepsis. Corticosteroids in sepsis/septic shock has been a controversial topic as the exact dose, which steroid to use, which patients will benefit and when to start them have all been debated. ...Read More