Escolar Documentos
Profissional Documentos
Cultura Documentos
Learning Objectives
To review adrenal function in
critically ill patients
To review the rationale for
supplementation with
corticosteroids during septic
shock
To review relevant recent
studies evaluating
corticosteroids replacement in
patients with septic shock
Effects on cardiovascular
system
Increasing mean blood pressure
Increasing pressor sensitivity
Decreasing the duration of use of
catecholamines during septic
shock
Annane D, Cavaillon JM. Shock; 20 (3) 2003
Glucocorticoids
Inhibition of pro - imflammatory
cytokine production
Regulation of anti-inflammatory
cytokine
Inhibition of inflammatory mediators
Modulation of cell markers
Modulation of apoptosis
Annane D, Cavaillon JM. Shock; 20 (3) 2003
Increase:
CO and blood flow by
1 and receptors
Tissue metabolism via
gluconeogenesis
Oxygen dissociation
Synthesis of IL-4 + IL10
Inappropriate dosing?
Timing issues, tissue penetration
What is new?
Results
Shock reversal in
15/22 (68%) HC pts
4/19 (21%) placebo pts
Mortality:
p=.007
p=.09
Results
Median time of VP support
HC pts:
2 days,
placebo pts:
7 days
p=.005
Results
Multivariate analysis
SOFA
OR 2.09
Randomization
TIME 0
At 8 hours
Hydrocortisone
50 mg IV QID
Eligibility
and
ACTH test
PLACEBO
For 7 days
+
Fludrocortisone PO
50 g/d for 7 days
Annane et al. JAMA 2002;288:862-71.
Patient Selection
Inclusion criteria
>18 years
Documented site
T>38.3 or <35.6c
HR > 90 bpm
SBP<90 mm Hg (fluids &
>5 g/kg/min dopamine)
Mechanical ventilation
PaO2/FiO2 < 280 or urine
output <0.5ml/kg/h or
lactate > 2 mmol/l
ACTH test
Exclusion criteria
Pregnancy
Evidence for AMI, PE
Need for corticosteroids
Contraindication to
steroids
Study Endpoints
Primary
Secondary
1.00
0.80
0.80
TREATMENT
TREATMENT
0.60
0.60
0.40
0.40
PLACEBO
0.20
0.20
P = 0.02
P = 0.03
0.00
0
14
Time (days)
21
PLACEBO
28
0.00
14
21
Time (days)
28
Probability of survival
28-day
28-day survival
survival and
and relative
relative adrenal
adrenal
insufficiency
insufficiency
1.00
max 9 g/dl
0.00
14
Time (days)
21
28
SUMMARY
Glucocorticoids display wide spectrum of
anti-inflammatory properties
Short courses of high dose corticosteroids
do not affect mortality from severe sepsis
& septic shock
Sepsis and septic shock may be associated
with relative adrenal insufficiency
SUMMARY
In vasopressor dependent septic shock, a
low dose of corticosteroids :
attenuated inflammation
restores vessels reactivity to
vasopressor agents
shortens the time on vasopressor agent
improves survival