Review of the use of hydrocortisone in intensive care patients with sepsis

Introduction

Corticosteroids may be beneficial in septic shock. Hydrocortisone (HC) has been the most widely studied steroid and is used on our ICU.

Aim

The aim of the study was to review the use of HC on the ICU, adherence to evidence-based guidelines, and the effect on inotrope (INO) and vasopressor (VP) requirements.

Method

Prescriptions were reviewed daily to identify patients (pts) on INO/VPs. Pts were excluded if corticosteroids were administered for other indications. Pt demographics, details of the HC prescription, INO/VP doses, and markers of sepsis were recorded.

Results

Twenty-five pts fulfilled the trial criteria for shock in the time period of this audit and 17 were prescribed steroids. However three were in cardiogenic rather than septic shock. Norepinephrine (NE) was used in 23, dobutamine (DB) in four and epinephrine (EPI) in three pts whilst five pts received more than one INO/VP. The median time to introduction of HC was 76 hours and 12 (17) did not adhere to ICU guidelines. The dose (expressed as mean dose per day, MDD) of NE fell from 0.30 μg/kg/min to 0.15 μg/kg/min over the following 48 hours (P < 0.02). The MDD for DB and EPI also decreased following HC administration. At the same time points, the MDD of NE in pts not receiving HC was lower, with a non-significant reduction in MDD over the same time frame. HC pts were on INO/VPs longer than the non-HC group (166 hours vs 112 hours) and had higher TISS scores (58.6 vs 49.8).

Conclusion

This audit confirms the beneficial effect of steroids on VP/INO requirements in septic shock. Non-adherence to the therapy guidelines in prescribing was common, probably due to anxieties surrounding the perceived detrimental effects of steroids in early sepsis and lack of prescription review.

Table Mean daily inotrope and vasopressor doses