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June 10, 2009

Living With Uncertainty in the Intensive Care Unit: Should Patients With Sepsis Be Treated With Steroids?

Author Affiliations

Author Affiliations: Department of Medicine, McMaster University, Hamilton, Ontario, Canada (Dr Jaeschke); CRISMA Laboratory, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Angus). Dr Angus is also Contributing Editor, JAMA.

JAMA. 2009;301(22):2388-2390. doi:10.1001/jama.2009.829

Physicians who practiced medicine 25 years ago likely remember the use of high-dose intravenous steroids, such as 1-g boluses of methylprednisolone, for septic shock. The practice was fueled by anecdotes of miraculous recoveries, but large randomized trials failed to demonstrate benefit and raised the specter of possible harm. Steroids were abandoned and lay dormant for years, until recent studies suggested that septic shock may be exacerbated by relative adrenal insufficiency and that smaller dose of steroids for longer periods of time may be beneficial. In 2002, in a multicenter French study, Annane et al1 reported lower mortality among patients in septic shock who were randomized to a 1-week course of low-dose steroids. This study ignited such rapid interest in steroids that the United States temporarily ran out of hydrocortisone. For those who lament the usually slow adoption of evidence into clinical practice, this event was a marked departure from the norm. Subsequent meta-analyses, systematic reviews, and professional society guidelines all echoed the notion that vasopressor-dependent septic shock should be treated with corticosteroids.

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