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Topic: Current Concepts in Wound Healing

Corticosteroid - an uncertainty in management

of sepsis

Kanica Yashi

Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15232, USA.
Address for correspondence: Dr. Kanica Yashi, Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15232, USA.
E‑mail: kay42@pitt.edu

Sir, any significant difference in 28‑day mortality. The median
time to vasopressor withdrawal and shock reversal was
The purpose of this letter is to review the literature 9 days in the placebo group and was 7 days in treatment
and bring the facts related to ambiguity in the use of group (P = 0.01). [3,4] The strength of the study was the
corticosteroid in the management of sepsis.
big sample size and the randomization, however, the use of
Sepsis is defined as systemic response to infection and both glucocorticoid and a mineralocorticoid was a marked
is diagnosed as per ACCS/SCCP consensus conference weakness making distinctions between the effects of each
committee, 1992 guidelines. Progression of sepsis to drug difficult. [1]
[1]
septic shock is caused by series of immune responses. [7]
[2]
For many decades in the past steroids have been used in Keh et al. performed a randomized double blinded
the management of sepsis but there has been an ambiguity placebo controlled crossover trial on 40 patients with
in their use in septic shock, doses, duration of therapy septic shock to investigate the effects of LDC (100 mg
effectiveness. However, recent studies have shown it to be bolus followed by 10 mg/h for the rest of 3 days) on
effective in septic shock associated with “relative adrenal immunologic parameters and hemodynamic parameters.
insufficiency”. Cortisol increases at times of physiological It was seen that plasma cortisol levels increased
[3]
stresses (e.g. sepsis, major injury, surgery, burns) due to to 5 folds in each group and were associated with
activation of the hypothalamus pituitary axis. Suboptimal stabilization of hemodynamic parameters. After 24 h of
cortisol production during the septic shock has been administration of corticosteroid the plasma concentration
termed as relative adrenal insufficiency and has been of interleukin‑6 (IL‑6), IL‑8, IL‑10 and tumor necrosis
related to increased mortality in patients with sepsis but factor (TNF‑1) and TNF‑2 were significantly lower in the
its actual existence remains controversial. The biochemical first group (received hydrocortisone) compared to the
diagnosis of adrenal insufficiency by adrenocorticotropic second one (did not receive hydrocortisone) (P = 0.01).
hormone (ACTH) tests were thought to be unreliable in The strength of the study was that each patient
critically ill patients. Also, measuring total cortisol may received the intervention and served as his or her own
not be accurate in severely ill patients due to fluctuating control. However, the study was limited by the fact that
levels of cortisol binding globulins. [4,5] hypothalamic‑pituitary‑adrenal axis was not addressed in
this study. [1]
Several studies are available that provides clinical evidences
related to the use of corticosteroids in sepsis. The French CORTICUS has evaluated the efficacy of LDC in a broad
[8]
[6]
trial, in a randomized control trial on 229 patients, population of patients (regardless of adrenal function)
revealed that there was reduction in 28‑day mortality on within 72 h of onset of shock. A total of 499 patients were
treatment with low dose corticosteroids (LDCs). Those randomized to treatment (50 mg hydrocortisone bolus
who responded to ACTH stimulation test (maximum every 6 h for 5 days, then 50 mg hydrocortisone every
increase in serum cortisol of > 9 µg/L) did not show

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How to cite this article: Yashi K. Corticosteroid - an uncertainty in
DOI: management of sepsis. Plast Aesthet Res 2015;2:284-5.
10.4103/2347-9264.165442
Received: 28-11-2014; Accepted: 19-01-2015

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