News: Just one fourth of septic shock patients receive corticosteroids in ICU, study shows

According to a recent study published in Critical Care Explorations, the percentage of patients with septic shock that were treated with early corticosteroids varied widely by attending physician and intensive care unit (ICU), with a range from 9.5% to 46.2% and a median of 21.8%. Also, researchers found that 24.3% were treated with corticosteroids within two days of vasopressor initiation, MedPage Today reported.

The study used the electronic health record of a multi-hospital health system that included nine hospitals with 26 ICUs. Researchers identified 5,322 patients with vasopressor-dependent septic shock admitted between 2018 and 2020, with a mean age of 65 and the majority being male. They found that, while both groups of patients who were treated with early corticosteroids were similar in ICU admission source, surgical status, and mechanical ventilation, the patients who received early corticosteroids had a higher mean Sequential Organ Failure Assessment (SOFA) score (7.3 vs. 6.1), a higher median maximum vasopressor dose (0.50 vs 0.20 µg/kg/min), and a higher in-hospital mortality rate (45.7% vs 32.5%) than those not given corticosteroids. Patients who received early corticosteroids also had shorter hospital lengths of stay (14 vs. 14.9 days) and shorter ICU lengths of stay (6.9 vs. 7.5 days) than those who didn’t.

When researchers limited the cohort to only physicians treating more than 10 patients, the percentage of patients treated with early corticosteroids saw an even wider range, from 2.9% to 83.3%. Physicians who prescribed corticosteroids more frequently also did so at a lower dose of vasopressors.

“Vasopressor-dependent septic shock is present in about 10% of patients admitted to the ICU and is associated with in-hospital mortality rates approaching 40%,” the authors explained. “Although a hallmark of septic shock is uncontrolled systemic inflammation, few evidence-based treatments for septic shock target the inflammatory cascade that leads to organ dysfunction and death."

While corticosteroids are the one major exception to this, with randomized trials suggesting that corticosteroids can speed the resolution of shock, reduce organ dysfunction, and lower short-term mortality, the researchers pointed out that these beneficial effects are likely modest. They also stated that corticosteroids may have damaging side effects such as neuromuscular weakness, hyperglycemia, and superinfection. They noted that current clinical practice guidelines for patients with vasopressor-dependent septic shock “leave considerable room for practice variation on the part of individual physicians.”

To change practice, the researchers suggested that a systemic approach would be necessary. “These findings have several implications for efforts to reduce variation and standardize practice in critical care,” they wrote in the study. “Specifically, our results underscore the importance of deploying multilevel interventions in the effort to improve evidence uptake, particularly in scenarios when the evidence is not definitive. Neither physician-level interventions, such as online education, nor ICU-level interventions, such as clinical protocols, are likely to be influential by themselves.”

Editor’s note: To read MedPage Today’s coverage of this story, click here. To access the Critical Care Explorations study, click here.