Abstract
Corticosteroids have proven to be effective as adjunctive treatment in sepsis and severe typhoid fever when used early and in high doses. If corticosteroids are given in high doses (30 mg/kg), they should be administered in 1–2 doses, and not to exceed 4 total doses within 24 hours. The efficacy of the drug may be diminished in more severe sepsis, but use of corticosteroids in severe sepsis may delay death. If the benefit of corticosteroid use in late sepsis is only to prolong impending death, then steroid administration is probably futile; however, the alternative view is that corticosteroid use may constitute one step in a series leading to shock reversal and recovery. Risks and benefits of corticosteroid use should be tailored to the individual patient with consideration given to the nature and extent of the underlying disease. Although the pathophysiology of the sepsis syndrome remains elusive, new therapeutic regimens may evolve using nonsteroidal anti-inflammatory drugs and neuropeptide antagonists. As with corticosteroids, their application before or early after the onset of shock appears more beneficial; however, the patient population that will benefit most from treatment with these drugs remains, for the most part, unidentified, and more clinical trials are needed.
Résumé
Les corticostéroïdes ont fait leur preuve en tant qu'agent thérapeutique complémentaire quand ils sont employés précocement et à hautes doses dans l'infection et la fièvre typhoïde. Si les corticostéroïdes sont donnés à hautes doses (30 mg/kg), ils doivent être administrés en 1–2 doses et ne jamais dépasser 4 doses par 24 heures. L'efficacité du médicament peut être faible dans les infections graves, il est alors seulement susceptible de retarder le décès. En fait, si l'emploi se limite à ce seul bénéfice, il paraît inutile d'y avoir recours. A l'inverse, la corticothérapie peut représenter une étape utile et efficace du traitement du choc. Les bénéfices et les risques de la corticothérapie doivent être appréciés en fonction de chaque malade et plus particulièrement de la nature et de l'intensité de l'affection dont il est victime. Bien que la physiopathologie du syndrome infectieux reste insaisissable, de nouveaux protocoles thérapeutiques comportant des anti-inflammatoires non stéroïdiens et des antagonistes neuropeptidiques peuvent être employés. Comme pour les corticoïdes leur usage avant ou au début du choc donne les meilleurs résultats. En fait, la population des malades qui peut bénéficier de l'emploi de ces agents médicamenteux n'est pas parfaitement définie et de très nombreux essais cliniques sont indispensables pour définir les meilleures indications.
Resumen
Los corticosteroides han probado ser efectivos como tratamiento adyuvante cuando se utilizan precozmente y en altas dosis en la sepsis y en la fiebre tifoidea grave. Si los corticosteroides son administrados en altas dosis (30 mg/kg), éstos deben darse en 1–2 dosis y no exceder un total de 4 dosis en 24 horas. La eficacia de la droga puede verse disminuida en casos de sepsis mas severa, pero su uso en el estado séptico puede diferir la mortalidad. Si el beneficio del uso de los corticosteroides en sepsis tardía es únicamente el de retardar una muerte inminente, entonces la administración de esteroides sería fútil; sinembargo, la perspectiva alterna es que el uso de corticosteroides constituye un escalón de una serie de eventos que resultan en la reversion del shock y la recuperation. Los riesgos y los beneficios del uso de corticosteroides deben ser ajustados a cada paciente individual con la debida consideración a la naturaleza y gravedad de la enfermedad de base. Aunque la patofisiología del síndrome de sepsis se mantiene elusivo, es previsible que nuevos regimenes terapéuticos puedan ser desarrollados con el uso de drogas anti-inflamatorias no esteroides y antagonistas neuropéptidos. Al igual que con los corticosteroides, su aplicación antes o muy pronto después de la iniciacion del shock parece ser de mayor beneficio; sinembargo, todavía no ha sido posible establecer cual es la población de patientes que se puede beneficiar mayormente de la terapia con estas drogas, y son necesarios mas estudios y ensayos clínicos.
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Long, W.M., Sprung, C.L. Corticosteroids, nonsteroidal anti-inflammatory drugs, and naloxone in the sepsis syndrome. World J. Surg. 11, 218–225 (1987). https://doi.org/10.1007/BF01656405
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DOI: https://doi.org/10.1007/BF01656405