Skip to main content

Advertisement

SpringerLink
Log in

Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

The Surviving Sepsis Campaign (SSC) developed guidelines and treatment bundles for the administration of steroids in adult septic shock. However, it is not clear how this has affected clinical practice or patient outcome.

Design and setting

The SSC has developed an extensive database to assess the overall effect of its guidelines on clinical practice and patient outcome. This analysis focuses on one particular element of the SSC’s management bundle, namely, the administration of low-dose steroids in adult septic shock. This analysis was conducted on data submitted from January 2005 through March 2010 including 27,836 subjects at 218 sites.

Main results

A total of 17,847 (of the total 27,836) patients in the database required vasopressor therapy despite fluid resuscitation and therefore met the eligibility criteria for receiving low-dose steroids. A total of 8,992 patients (50.4 %) received low-dose steroids for their septic shock. Patients in Europe (59.4 %) and South America (51.9 %) were more likely to be prescribed low-dose steroids compared to their counterparts in North America (46.2 %, p < 0.001). The adjusted hospital mortality was significantly higher (OR 1.18, 95 % CI 1.09–1.23, p < 0.001) in patients who received low-dose steroids compared to those who did not. There was still an association with increased adjusted hospital mortality with low-dose steroids even if they were prescribed within 8 h (OR 1.23, 95 % CI 1.13–1.34, p < 0.001).

Conclusions

Steroids were commonly administered in the treatment of septic shock in this subset analysis of the Surviving Sepsis Campaign database. However, this was associated with an increase in adjusted hospital mortality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Martin GS, Mannino DM, Eaton S, Moss M (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348:1546–1554

    Article  PubMed  Google Scholar 

  2. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29:1303–1310

    Article  PubMed  CAS  Google Scholar 

  3. Woodward B, Cartwright M (2009) Safety of drotrecogin alfa (activated) in severe sepsis: data from adult clinical trials and observational studies. J Crit Care 24:595–602

    Article  PubMed  Google Scholar 

  4. Russell JA, Walley KR, Singer J, Gordon AC, Hebert PC, Cooper DJ, Holmes CL, Mehta S, Granton JT, Storms MM, Cook DJ, Presneill JJ, Ayers D (2008) Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 358:877–887

    Article  PubMed  CAS  Google Scholar 

  5. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J (2008) Hydrocortisone therapy for patients with septic shock. N Engl J Med 358:111–124

    Article  PubMed  CAS  Google Scholar 

  6. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D (2006) Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 34:344–353

    Article  PubMed  Google Scholar 

  7. Maxime V, Lesur O, Annane D (2009) Adrenal insufficiency in septic shock. Clin Chest Med 30:17–27 (vii)

    Google Scholar 

  8. Annane D, Sebille V, Troche G, Raphael JC, Gajdos P, Bellissant E (2000) A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 283:1038–1045

    Article  PubMed  CAS  Google Scholar 

  9. Annane D, Bellissant E (2000) Prognostic value of cortisol response in septic shock. JAMA 284:308–309

    Article  PubMed  Google Scholar 

  10. Sprung CL, Annane D, Singer M, Cuthbertson BH, Briegel J (2009) Steroids in patients with septic shock. Chest 136:323–324

    Article  PubMed  Google Scholar 

  11. LaRosa SP (2005) Use of corticosteroids in the sepsis syndrome: what do we know now? Cleve Clin J Med 72:1121–1127

    Article  PubMed  Google Scholar 

  12. Lipiner-Friedman D, Sprung CL, Laterre PF, Weiss Y, Goodman SV, Vogeser M, Briegel J, Keh D, Singer M, Moreno R, Bellissant E, Annane D (2007) Adrenal function in sepsis: the retrospective Corticus cohort study. Crit Care Med 35:1012–1018

    Article  PubMed  Google Scholar 

  13. Groeneveld AB, Molenaar N, Beishuizen B (2008) Should we abandon corticosteroids during septic shock? No. Curr Opin Crit Care 14:384–389

    Article  PubMed  Google Scholar 

  14. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J (2008) Hydrocortisone therapy for patients with septic shock. New Engl J Med 358:111–124

    Article  PubMed  CAS  Google Scholar 

  15. Vincent JL (2008) Steroids in sepsis: another swing of the pendulum in our clinical trials. Crit Care 12:141

    Article  PubMed  Google Scholar 

  16. Levy MM, Pronovost PJ, Dellinger RP, Townsend S, Resar RK, Clemmer TP, Ramsay G (2004) Sepsis change bundles: converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med 32:S595–S597

    Article  PubMed  Google Scholar 

  17. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873

    Article  PubMed  Google Scholar 

  18. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36:296–327

    Article  PubMed  Google Scholar 

  19. Townsend SR, Schorr C, Levy MM, Dellinger RP (2008) Reducing mortality in severe sepsis: the Surviving Sepsis Campaign. Clin Chest Med 29:721–733 (x)

    Google Scholar 

  20. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S, Angus DC, The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 36:222–231

  21. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31:1250–1256

    Article  PubMed  Google Scholar 

  22. [cited 2012 May 10] Available from: http://.hhs.gov/ohrp/qualityfaq.html

  23. Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaud P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871

    Article  PubMed  CAS  Google Scholar 

  24. Meduri GU, Belenchia JM, Estes RJ, Wunderink RG, el Torky M, Leeper KV Jr (1991) Fibroproliferative phase of ARDS. Clinical findings and effects of corticosteroids. Chest 100:943–952

    Article  PubMed  CAS  Google Scholar 

  25. Confalonieri M, Urbino R, Potena A, Piattella M, Parigi P, Puccio G, Della Porta R, Giorgio C, Blasi F, Umberger R, Meduri GU (2005) Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 171:242–248

    Article  PubMed  Google Scholar 

  26. Beale R, Janes JM, Brunkhorst FM, Dobb G, Levy MM, Martin GS, Ramsay G, Silva E, Sprung CL, Vallet B, Vincent JL, Costigan TM, Leishman AG, Williams MD, Reinhart K (2010) Global utilization of low-dose corticosteroids in severe sepsis and septic shock: a report from the PROGRESS registry. Crit Care 14:R102

    Article  PubMed  Google Scholar 

  27. Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G, Garnacho-Montero J, Ibanez J, Palencia E, Quintana M, de la Torre-Prados MV (2008) Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 299:2294–2303

    Article  PubMed  CAS  Google Scholar 

  28. Kalil AC, Sun J (2008) Why are clinicians not embracing the results from pivotal clinical trials in severe sepsis? A bayesian analysis. PLoS One 3:e2291

    Article  PubMed  Google Scholar 

  29. Sprung CL, Goodman S, Weiss YG (2009) Steroid therapy of septic shock. Crit Care Clin 25:825–834 (x)

    Google Scholar 

  30. Meduri GU, Belenchia JM, Estes RJ, Wunderink RG, el Torky M, Leeper KV Jr (1991) Fibroproliferative phase of ARDS. Clinical findings and effects of corticosteroids. Chest 100:943–952

    Article  PubMed  CAS  Google Scholar 

  31. Benson K, Hartz AJ (2000) A comparison of observational studies and randomized, controlled trials. N Engl J Med 342:1878–1886

    Article  PubMed  CAS  Google Scholar 

  32. Ferrer R, Artigas A, Suarez D, Palencia E, Levy MM, Arenzana A, Perez XL, Sirvent JM (2009) Effectiveness of treatments for severe sepsis: a prospective, multicenter, observational study. Am J Respir Crit Care Med 180:861–866

    Article  PubMed  CAS  Google Scholar 

  33. Lindenauer PK, Rothberg MB, Nathanson BH, Pekow PS, Steingrub JS (2010) Activated protein C and hospital mortality in septic shock: a propensity-matched analysis. Crit Care Med 38:1101–1107

    Google Scholar 

Download references

Acknowledgments

The Surviving Sepsis Campaign was funded in part by unrestricted educational grants from Eli Lilly Co. and Edwards Lifesciences

Conflicts of interest

Brian Casserly, Herwig Gerlach, Gary Philips, John C. Marshall, Stanley Lemeshow and Mitchell M. Levy report no conflicts of interest with regard to this manuscript.

Author information

Authors and Affiliations

  1. University of Limerick, Graduate Entry Medical School, Limerick, Ireland

    Brian Casserly

  2. The Brown Alpert Medical School, Providence, RI, USA

    Brian Casserly & Mitchell M. Levy

  3. Division of Anesthesiology and Critical Care, Vivantes-Klinikum Neukoelln, Berlin, Germany

    Herwig Gerlach

  4. The Ohio State University Center for Biostatistics, Columbus, OH, USA

    Gary S. Phillips

  5. The Ohio State University College of Public Health, Columbus, OH, USA

    Stanley Lemeshow

  6. Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Canada

    John C. Marshall

  7. Department of Surgery and Division of Emergency Medicine, Surgical/Trauma Critical Care, Barnes Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA

    Tiffany M. Osborn

  8. Division of Critical Care, Rhode Island Hospital, Providence, RI, USA

    Mitchell M. Levy

Authors
  1. Brian Casserly
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Herwig Gerlach
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gary S. Phillips
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stanley Lemeshow
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. John C. Marshall
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tiffany M. Osborn
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mitchell M. Levy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Brian Casserly.

Additional information

This article is discussed in the editorial available at: doi:10.1007/s00134-012-2721-y.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Cite this article

Casserly, B., Gerlach, H., Phillips, G.S. et al. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Med 38, 1946–1954 (2012). https://doi.org/10.1007/s00134-012-2720-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-012-2720-z

Keywords

Search

Navigation