A survey of corticosteroid use for the management of septic shock

Background: Critical illness is associated with pituitary-adrenal axis dysfunction, and may cause adrenal insufficiency that manifests as septic shock that is poorly responsive to fluid or inotropic therapy. Administering a low-dose corticosteroid to these patients results in faster shock resolution, but there is controversy regarding its effect on patient mortality. This survey aimed to describe how survey respondents are interpreting the current literature and using corticosteroids in patient management. Method: A survey was conducted during the 2011 annual congress of the South African Society of Anaesthesiologists. Results: Of the 65 respondents who completed the survey, all (except one specialist) had a background in anaesthesia or critical care. The majority of respondents agreed with the Surviving Sepsis Campaign definitions for sepsis and septic shock. A "typical" respondent would administer a total daily dose of 200 mg hydrocortisone, in boluses, to septic shock patients requiring inotropic support, or who were poorly responsive to inotropes. They would not use an adrenocorticotropic hormone stimulation test to identify these patients. Once shock resolved, or inotropes were no longer required, they would wean the hydrocortisone. More than 40% of respondents would use corticosteroids in clinical scenarios in which no patient benefit has been shown, and which might cause patient harm. Conclusion: Respondents use corticosteroids as recommended by the Surviving Sepsis Campaign guidelines, but would extend this use to other clinical scenarios, i.e. sepsis without hypotension and for non-septic shock, which might cause patient harm. When making clinical decisions, more emphasis should be placed on patient-important outcomes than on surrogate outcomes.