Steroids sepsis nejm

Background: Randomized clinical trials evaluating the efficacy of adjunctive corticosteroids in septic shock have shown conflicting evidence of clinical relevance. Two trials in particular [2][3] looked at lower dose hydrocortisone (200mg/day) and its effect on mortality in patients with septic shock resulting in conflicting results in regards to mortality, but both showing earlier reversal of shock in patients treated with hydrocortisone. The current surviving sepsis guidelines recommend the use of hydrocortisone in patients with septic shock after adequate fluid resuscitation and use of vasopressors who have not achieved hemodynamic stability, but this recommendation is classified as weak evidence (Level 2C). Due to these weak recommendations there has been a variability in use of corticosteroids in septic shock. On Jan 19 th , 2018 the ADRENAL Trial results were published trying to once and for all answer the question of adjunctive steroids in septic shock.

PCCM: The 1st International Sepsis Forum on Sepsis in Infants and Children with Dr. Adrienne Randolph
Adrienne Randolph, MD, MSc, served as guest editor for the May 2005 supplement of Pediatric Critical Care Medicine. Dr. Randolph shares her thoughts on the importance of the 1st International Sepsis Forum on Sepsis in Infants and Children and the Pediatric Acute Lung Injury and Sepsis Investigator’s (PALISI) Network. She also highlights the most important aspects from the supplement, which she played such an instrumental role in producing. Ped Crit Care Med. 2005;6(3) (Suppl S1-S2)

(NEJM 2008;358(2):125) Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis Background The role of intensive insulin therapy in patients with severe sepsis is uncertain. Fluid resuscitation improves survival among patients with septic shock, but evidence is lacking to support the choice of either crystalloids or colloids. Methods In a multicenter, two-by-two factorial trial, we randomly assigned patients with severe sepsis to receive either intensive insulin therapy to maintain euglycemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/), or modified Ringer’s lactate for fluid resuscitation. The rate of death at 28 days and the mean score for organ failure were coprimary end points. Results The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (112 mg per deciliter [ mmol per liter]) than in the conventional-therapy group (151 mg per deciliter [ mmol per liter], P ). However, at 28 days, there was no significant difference between the two groups in the rate of death or the mean score for organ failure. The rate of severe hypoglycemia (glucose level, 40 mg per deciliter [ mmol per liter]) was higher in the intensive-therapy group than in the conventional-therapy group (% vs. %, P ), as was the rate of serious adverse events (% vs. %, P=). HES therapy was associated with higher rates of acute renal failure and renal-replacement therapy than was Ringer’s lactate. Conclusions The use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycemia. As used in this study, HES was harmful, and its toxicity increased with accumulating doses. ( number, NCT00135473 [] .)

If we have learned anything from our history, it is that even things that seem benign such as tight glycemic control can be harmful if not carefully looked at systematically. Whether this therapy eventually does turn out to be life saving (or whether it causes harm), we must remember that our primary job as clinicians is to administer therapies that have been vigorously proven by science and not simply based on parachute reasoning. If we hold ourselves to a standard less than that, and one based on logical reasoning then we would have never demonstrated in multiple subsequent trials that tight glycemic control was actually harmful to patients. Therapies based on only logic should only be considered when there are no other alternatives.

Steroids sepsis nejm

steroids sepsis nejm

If we have learned anything from our history, it is that even things that seem benign such as tight glycemic control can be harmful if not carefully looked at systematically. Whether this therapy eventually does turn out to be life saving (or whether it causes harm), we must remember that our primary job as clinicians is to administer therapies that have been vigorously proven by science and not simply based on parachute reasoning. If we hold ourselves to a standard less than that, and one based on logical reasoning then we would have never demonstrated in multiple subsequent trials that tight glycemic control was actually harmful to patients. Therapies based on only logic should only be considered when there are no other alternatives.

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