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Hydrocortisone makes shock reversal more likely.

 

 

For every 3 patients given hydrocortisone, 1 extra shock reversal, compared to placebo.
For every 4 patients given hydrocortisone, one less death at 28 days, compared to placebo.
Level 1-  Small sample size.

 

Citation/s:    Reversal of late septic shock with supraphysiological doses of hydrocortisone. Critical Care Medicine 1998; 26: 645-50.
 

Lead author's name and fax:  P Bollaert, Service de Reanimation Medicale, Hopital Central, 54035 Nancy Cedex, France.  

 

Three-part Clinical Question: In patients with septic shock, does the use of low dose steroid compared to standard therapy, affect 28-day mortality?
 

Search Terms: 1. exp sepsis/ or severe sep$.tw or sept$.tw or sepsi$.tw (50301), 2. exp critical care/ or critical ca$.tw or intensive ca$.tw (22553), 3. exp hydrocortisone/ or hydrocort$.tw or exp steroids/ or steroi$.tw (110778), 4. 1 and 2 and 3 (107), 5. therapy filter (652119), 6. 4 and 5 (70)

 

The Study:   Double-blinded concealed randomised controlled trial with intention-to-treat.
 

The Study Patients: Sepsis defined by ACCP/SCCM criteria.    All were on inotropes for > 48 hours. Excluded if: underlying fatal disease, with-holding therapy considered, recent ulcer, gastrointestinal bleeding, or corticosteroid therapy. All patients had short ACTH test, excluded if inadequate response.
 

Control group (N = 19; 19 analysed): Identical placebo.
 

Experimental group (N = 22; 22 analysed): 100 mg hydrocortisone 3 times a day for ³ 5 days. If shock reversal, then 50mg x 3 for 3 days, and then 25 mg x 3 for 3 days, then stopped.

 

The Evidence:

Outcome

Time to Outcome

CER

EER

RRR

ARR

NNT

Shock reversal (stable SBP > 90mmHg ³ 24h, lactate < 2 mmol.l-1).

7 day

0.211

0.682

-223%

-0.471

-2

95% Confidence Intervals:

-350% to -96%

-0.738 to -0.204

-5 to -1

Mortality

28 day

0.632

0.318

50%

0.314

3

95% Confidence Intervals:

4% to 96%

0.023 to 0.605

2 to 44

 

Comments:


1. Note high mortality in control group (greater than average).
2. In small samples, one additional event either way, can have a major effect.
3. Hydrocortisone a cheap drug.
4. Same group carrying out larger 200 v 200 study. We'll be more certain of effect after this.

 

Appraised by: Malcolm Daniel, Department of Anaesthesia, Glasgow Royal Infirmary ; Monday, October 01, 2001      Email: md23s@udcf.gla.ac.uk

 

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