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July 6, 2011

Hydrocortisone and Treatment of Multiple Trauma

Author Affiliations

Author Affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada (eddy.fan@uhn.on.ca).

JAMA. 2011;306(1):40-42. doi:10.1001/jama.2011.897

To the Editor: Dr Roquilly and colleagues presented the results of their randomized controlled trial of hydrocortisone therapy for patients with multiple trauma.1 The Hydrocortisone Polytraumatise (HYPOLYTE) study demonstrated a significant reduction in hospital-acquired pneumonia and duration of mechanical ventilation. However, identification of the subgroup of trauma patients who may benefit from low-dose hydrocortisone therapy using their definitions for corticosteroid insufficiency (ie, basal cortisolemia <15 μg/dL [to convert to nmol/L, multiply by 27.588] or maximal increase in cortisol ≤9 μg/dL following a short corticotropin test) is problematic. A number of studies have demonstrated the limitations of using either random cortisol levels or response to the short corticotropin test in the critically ill.2 A significant reduction in hospital-acquired pneumonia at day 28 (hazard ratio, 0.51; 95% confidence interval [CI], 0.30-0.83) and an increase in ventilator-free days (4 days; 95% CI, 2-7) were observed in the intention-to-treat analysis including all patients, with the benefit not limited to those who met the criteria for corticosteroid insufficiency. The authors acknowledged that their definition did not conform to the most recent consensus statement from the American College of Critical Care Medicine (ACCM)3: 15% of patients would not have been classified as corticosteroid insufficient if the ACCM definitions had been used. A sensitivity analysis restricted to patients meeting the ACCM definitions would be interesting.