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Nedel W, Lisboa T, Salluh JIF. What Is the Role of Steroids for Septic Shock in 2021? Semin Respir Crit Care Med 2021; 42:726-734. [PMID: 34544190 DOI: 10.1055/s-0041-1733900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.
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Affiliation(s)
- Wagner Nedel
- Programa de Pós-Graduação em Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Programa de Pós-Graduação em Ciencias Pneumologicas, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Universidade Unilasalle, Canoas, Brazil
- Instituto de Pesquisa, HCOR, São Paulo, Brazil
| | - Jorge I F Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Al Duhailib Z, Farooqi M, Piticaru J, Alhazzani W, Nair P. The role of eosinophils in sepsis and acute respiratory distress syndrome: a scoping review. Can J Anaesth 2021; 68:715-726. [PMID: 33495945 PMCID: PMC7833890 DOI: 10.1007/s12630-021-01920-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Septic shock and acute respiratory distress syndrome (ARDS) are characterized by a dysregulated immune host response that may respond to steroid therapy. Eosinophils contribute to type 2 inflammation that often responds to steroid therapy; their role in immune dysregulation and outcomes in sepsis and ARDS is unclear. SOURCE A systematic search of Cochrane Library, MEDLINE, and EMBASE was performed from inception to 9 September 2020. The search comprised the following terms: eosinophils, sepsis, septic shock, and ARDS. Two reviewers independently screened abstracts and texts and extracted data on disease severity and clinical outcomes. PRINCIPAL FINDINGS Thirty-nine studies were identified: 30 evaluated serum eosinophil count in sepsis, one evaluated eosinophil activity in sepsis, three assessed bronchoalveolar lavage (BAL) eosinophil count in ARDS, four assessed eosinophil activity in ARDS, and one assessed peripheral eosinophil count in ARDS. Eleven studies showed an association between eosinopenia and sepsis, and eight studies found persistent eosinopenia at > 48 hr of intensive care unit admission to predict mortality and readmission in septic patients. Three studies found BAL eosinophil count to be low in ARDS, although one found that levels rose in late-phase ARDS. Three studies found eosinophil activity markers in BAL to be high in ARDS and correlate with ARDS severity. CONCLUSION Persistent peripheral eosinopenia is a marker of bacterial sepsis and is independently associated with poor outcomes. Bronchoalveolar lavage eosinophil counts are low in early-phase ARDS, but increase in late-phase ARDS, while elevated markers of eosinophil activity correlate with ARDS severity. Further studies understanding the mechanisms leading to eosinopenia in sepsis and increased eosinophil activity in ARDS are needed.
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Affiliation(s)
- Zainab Al Duhailib
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
| | - Malik Farooqi
- Department of Medicine, Division of Respirology, St Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Parameswaran Nair
- Department of Medicine, Division of Respirology, St Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
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Huber S, Weinberger J, Pilecky M, Lorenz I, Schildberger A, Weber V, Fuchs S, Posch W, Knabl L, Würzner R, Posch AE, Orth-Höller D. A high leukocyte count and administration of hydrocortisone hamper PCR-based diagnostics for bloodstream infections. Eur J Clin Microbiol Infect Dis 2021; 40:1441-1449. [PMID: 33547522 DOI: 10.1007/s10096-020-04126-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/13/2020] [Indexed: 12/14/2022]
Abstract
Bloodstream infections (BSIs) require an accurate and fast identification of causative pathogens. Molecular diagnostics, in particular polymerase chain reaction (PCR)-based approaches for BSI diagnostics directly from whole blood, suffer from limitations such as inhibition leading to invalid results. In this retrospective study, we analyzed 23 parameters for their potential interference with LightCycler SeptiFast PCR tests (n = 2167) routinely performed at our institution. The overall inhibition rate was 9.1%. Test date, type of ward, procalcitonin levels, high leukocyte counts, and absolute neutrophil count were significantly associated with inhibition. For a subset (n = 448), cut-off values for leukocyte counts of < 5700 cells/μL and ≥ 26,900 cells/μL were significantly associated with a low (5%) and high (67%) inhibition risk. For patients with a moderate to high leukocyte count (5700-26,900 cells/μL), the additional administration of hydrocortisone significantly increased the inhibition risk. Furthermore, freezing of blood samples prior to DNA extraction and SF testing appeared to neutralize inhibitory factors. It remains to be investigated whether other molecular diagnostic tests are susceptible to similar inhibiting parameters.
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Affiliation(s)
- Silke Huber
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | | | - Matthias Pilecky
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Ingo Lorenz
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Anita Schildberger
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Viktoria Weber
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria.,Christian Doppler Laboratory for Innovative Therapy Approaches in Sepsis, Danube University Krems, Krems, Austria
| | - Stefan Fuchs
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Wilfried Posch
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Ludwig Knabl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Reinhard Würzner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Andreas E Posch
- Ares Genetics GmbH, Karl-Farkas-Gasse 18, 1030, Vienna, Austria.
| | - Dorothea Orth-Höller
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria.
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Ying P, Yang C, Wu X, Cai Q, Xin W. Effect of hydrocortisone on the 28-day mortality of patients with septic acute kidney injury. Ren Fail 2020; 41:794-799. [PMID: 31880211 PMCID: PMC6735306 DOI: 10.1080/0886022x.2019.1658605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objectives: To evaluate the efficacy of hydrocortisone in patients with septic acute kidney injury (SAKI). Methods: This retrospective cohort study consisted of all consecutive patients with SAKI who were admitted to the Taizhou First People's Hospital from March 2016 to February 2018. The patients who were treated with usual care including antibiotics, fluid resuscitation, and blood glucose control were regarded as the control group, and those received add-on hydrocortisone by the clinicians' discretion was considered in the intervention group. Hydrocortisone was administered as a 50 mg intravenous bolus every six hours for seven days. To adjust the potential baseline differences between the hydrocortisone and control groups, a 1:1 propensity score matching (PSM) was performed to identify a matched control subject for each patient in the hydrocortisone group. Results: In the propensity-matched cohort, the 28-day mortality was significantly lower for patients in the hydrocortisone group (p = .04). Both Acute Physiology and Chronic Health Evaluation (APACHE) II and the Sequential Organ Failure Assessment (SOFA) scores were significantly lower at day 7 in the hydrocortisone group (both p < .01). Serum IL-1β, IL-6, and TNF-α concentrations significantly decreased for hydrocortisone group at day 7 (all p < .01). The levels of serum creatinine (SCr), Cystatin C (CysC), and procalcitonin (PCT) were significantly lower, while the levels of glomerular filtration rate (GFR) and urine volume were significantly higher for hydrocortisone group at day 7 (all p < .01). Conclusions: Glucocorticoid supplementation may improve renal function and reduce the 28-day mortality of patients with SAKI.
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Affiliation(s)
- Pan Ying
- Taizhou First People's Hospital, Taizhou, China
| | - Chenguang Yang
- Health Care Center for Women and Children of Huangyan District, Taizhou, China
| | - Xianlong Wu
- Taizhou First People's Hospital, Taizhou, China
| | - Qiqi Cai
- Taizhou First People's Hospital, Taizhou, China
| | - Wenwei Xin
- Taizhou First People's Hospital, Taizhou, China
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Meduri GU, Chrousos GP. General Adaptation in Critical Illness: Glucocorticoid Receptor-alpha Master Regulator of Homeostatic Corrections. Front Endocrinol (Lausanne) 2020; 11:161. [PMID: 32390938 PMCID: PMC7189617 DOI: 10.3389/fendo.2020.00161] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022] Open
Abstract
In critical illness, homeostatic corrections representing the culmination of hundreds of millions of years of evolution, are modulated by the activated glucocorticoid receptor alpha (GRα) and are associated with an enormous bioenergetic and metabolic cost. Appreciation of how homeostatic corrections work and how they evolved provides a conceptual framework to understand the complex pathobiology of critical illness. Emerging literature place the activated GRα at the center of all phases of disease development and resolution, including activation and re-enforcement of innate immunity, downregulation of pro-inflammatory transcription factors, and restoration of anatomy and function. By the time critically ill patients necessitate vital organ support for survival, they have reached near exhaustion or exhaustion of neuroendocrine homeostatic compensation, cell bio-energetic and adaptation functions, and reserves of vital micronutrients. We review how critical illness-related corticosteroid insufficiency, mitochondrial dysfunction/damage, and hypovitaminosis collectively interact to accelerate an anti-homeostatic active process of natural selection. Importantly, the allostatic overload imposed by these homeostatic corrections impacts negatively on both acute and long-term morbidity and mortality. Since the bioenergetic and metabolic reserves to support homeostatic corrections are time-limited, early interventions should be directed at increasing GRα and mitochondria number and function. Present understanding of the activated GC-GRα's role in immunomodulation and disease resolution should be taken into account when re-evaluating how to administer glucocorticoid treatment and co-interventions to improve cellular responsiveness. The activated GRα interdependence with functional mitochondria and three vitamin reserves (B1, C, and D) provides a rationale for co-interventions that include prolonged glucocorticoid treatment in association with rapid correction of hypovitaminosis.
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Affiliation(s)
- Gianfranco Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Memphis Veterans Affairs Medical Center, Memphis, TN, United States
| | - George P. Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Yamamoto R, Nahara I, Toyosaki M, Fukuda T, Masuda Y, Fujishima S. Hydrocortisone with fludrocortisone for septic shock: a systematic review and meta-analysis. Acute Med Surg 2020; 7:e563. [PMID: 32995018 PMCID: PMC7507448 DOI: 10.1002/ams2.563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 12/24/2022] Open
Abstract
AIM Combined hydrocortisone and fludrocortisone therapy for septic shock has not been evaluated with an independent systematic review. We aimed to elucidate the beneficial effects of a dual corticosteroid treatment regime involving both hydrocortisone and fludrocortisone for adult patients with septic shock on mortality. METHODS We searched the Medline, Cochrane CENTRAL, and ICHUSHI databases for reports published before April 2019. We included randomized controlled trials that compared the use of both hydrocortisone and fludrocortisone with either corticosteroid-free or hydrocortisone-only treatments on adult patients with septic shock. Three researchers independently reviewed the studies. The meta-analyses were undertaken to assess primary outcome (28-day mortality) and secondary outcomes (in-hospital mortality, long-term mortality, shock reversal, and adverse events). RESULTS Among the four studies eligible for data synthesis, we included 2,050 patients from three studies for quantitative synthesis. All studies used similar regimens (hydrocortisone and fludrocortisone for 7 days without tapering). The 28-day mortality rate was reduced after dual corticosteroid treatment (risk ratio, 0.88; 95% confidence intervals [CI], 0.78-0.99). The heterogeneity between the studies was low (I 2 = 0%). Patients who underwent dual corticosteroid treatment had lower long-term mortality rates (risk ratio, 0.90; 95% CI, 0.83-0.98) and higher rate of shock reversal after 28 days (odds ratio, 1.06; 95% CI, 1.01-1.12) than control patients. Adverse events (except for hyperglycemia) were similar among the treatment groups. CONCLUSIONS The available evidence suggests that a combination of fludrocortisone and hydrocortisone is more effective than adjunctive therapy and could be recommended for septic shock.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
| | - Isao Nahara
- Department of Anesthesiology and Critical Care MedicineNagoya Daini Red Cross HospitalNagoyaJapan
| | - Mitsunobu Toyosaki
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care MedicineGraduate School of MedicineUniversity of the RyukyusOkinawaJapan
| | - Yoshiki Masuda
- Department of Intensive Care MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Seitaro Fujishima
- Center for General Medicine EducationKeio University School of MedicineTokyoJapan
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Li X, Li M, Liu L, Tian X, Liang Y. Protective effects of glucocorticoid on liver injury in a rat sepsis model. Exp Ther Med 2019; 18:3153-3160. [PMID: 31572556 DOI: 10.3892/etm.2019.7899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Sepsis is one of the leading causes of death with unsatisfactory current treatments. The present study assessed the liver protective effect of glucocorticoids on different levels of inflammation in septic shock rats. A rat septic shock model was established by lipopolysaccharide (LPS) injection. Rats were divided into control (Control), high-inflammation treated with hydrocortisone (HT), high-inflammation non-treatment (HNT), low-inflammation treated with hydrocortisone (LT) and low-inflammation non-treatment (LNT) groups according to the levels of serum C-reactive protein (CRP), interleukin (IL)-6 and interferon (IFN)-γ. The mean arterial pressure and heart rate changes were continuously monitored and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured by an automatic biochemical analyzer. Hematoxylin and eosin (H&E) staining was performed to observe the pathological changes of liver tissue. Western blot analysis was used to detect the expression of p38 mitogen-activated protein kinase (MAPK) and NF-κB protein. The results demonstrated that following 7 days of treatment, there were no obvious differences in the serum CRP, IL-6 and IFN-γ levels between the HT group and the control group, whilst the HNT group, LT group and LNT group were significantly different compared with the HT and control groups. H&E staining demonstrated that the liver cells in the HT group were homogeneous following 7 days of treatment. Western blot analysis determined that the phosphorylation levels of p38MAPK and NF-κB in HT group were reduced significantly compared with the LT group, while there was no obvious difference with the control group after 7 days treatment. The present results indicated that glucocorticoids have better therapeutic effect on septic shock rats with high-inflammation compared with low-inflammation rats. The present study provides a novel approach for glucocorticoid treatment of septic shock.
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Affiliation(s)
- Xiaoli Li
- Department of Critical Care Medicine, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Meifeng Li
- Department of Critical Care Medicine, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Luyi Liu
- Department of Critical Care Medicine, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Xinghan Tian
- Department of Critical Care Medicine, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Yafeng Liang
- Department of Critical Care Medicine, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
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Ni YN, Liu YM, Wang YW, Liang BM, Liang ZA. Can corticosteroids reduce the mortality of patients with severe sepsis? A systematic review and meta-analysis. Am J Emerg Med 2018; 37:1657-1664. [PMID: 30522935 DOI: 10.1016/j.ajem.2018.11.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/07/2018] [Accepted: 11/26/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The effects of corticosteroids on clinical outcomes of patients with sepsis remains controversial. We aimed to further determine the effectiveness of corticosteroids in reducing mortality in adult patients with severe sepsis by comparison with placebo. METHODS Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that compared corticosteroids and placebo in adult patients with severe sepsis. The primary outcome was the mortality 28-day mortality and the secondary outcomes were mortality at longest follow up, occurrence, and reoccurrence of septic shock. RESULTS A total of 19 trials involving 7035 patients were pooled in our final analyses. No significant heterogeneity was found in any of the outcome measures. Compared with placebo, corticosteroids were associated with a lower 28-day mortality (RR 0.91, 95% CI 0.85-0.98, Z = 2.57, P = 0.01) both in patients having sepsis and in those who developed septic shock (RR 0.92, 95% CI 0.85-0.99, Z = 2.19, P = 0.03), while no significant difference was found in mortality with the longest follow up in patients either having sepsis (RR 0.94, 95% CI 0.89-1.00, Z = 1.93, P = 0.05), or occurrence (RR 0.83, 95% CI 0.56-1.24, Z = 0.90, P = 0.37) or reoccurrence of septic shock (RR 1.08, 95% CI 1.00-1.16, Z = 1.89, P = 0.06). CONCLUSIONS Corticosteroids were effective in reducing the 28-day mortality in patients with severe sepsis and in those with septic shock.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China
| | - Yuan-Ming Liu
- Department of Respiratory and Critical Care Medicine, People's Hospital of Pengzhou City, 611930, China
| | - Yi-Wei Wang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
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Heming N, Sivanandamoorthy S, Meng P, Bounab R, Annane D. Immune Effects of Corticosteroids in Sepsis. Front Immunol 2018; 9:1736. [PMID: 30105022 PMCID: PMC6077259 DOI: 10.3389/fimmu.2018.01736] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/13/2018] [Indexed: 12/29/2022] Open
Abstract
Sepsis, a life-threatening organ dysfunction, results from a dysregulated host response to invading pathogens that may be characterized by overwhelming systemic inflammation or some sort of immune paralysis. Sepsis remains a major cause of morbidity and mortality. Treatment is nonspecific and relies on source control and organ support. Septic shock, the most severe form of sepsis is associated with the highest rate of mortality. Two large multicentre trials, undertaken 15 years apart, found that the combination of hydrocortisone and fludrocortisone significantly reduces mortality in septic shock. The corticosteroids family is composed of several molecules that are usually characterized according to their glucocorticoid and mineralocorticoid power, relative to hydrocortisone. While the immune effects of glucocorticoids whether mediated or not by the intracellular glucocorticoid receptor have been investigated for several decades, it is only very recently that potential immune effects of mineralocorticoids via non-renal mineralocorticoid receptors have gained popularity. We reviewed the respective role of glucocorticoids and mineralocorticoids in counteracting sepsis-associated dysregulated immune systems.
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Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Laboratory Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-Le-Bretonneux, France
| | | | - Paris Meng
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France
| | - Rania Bounab
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Laboratory Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-Le-Bretonneux, France
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Besnier E, Clavier T, Compere V. The Hypothalamic–Pituitary–Adrenal Axis and Anesthetics. Anesth Analg 2017; 124:1181-1189. [DOI: 10.1213/ane.0000000000001580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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11
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Hamitouche N, Comets E, Ribot M, Alvarez JC, Bellissant E, Laviolle B. Population Pharmacokinetic-Pharmacodynamic Model of Oral Fludrocortisone and Intravenous Hydrocortisone in Healthy Volunteers. AAPS JOURNAL 2017; 19:727-735. [DOI: 10.1208/s12248-016-0041-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/30/2016] [Indexed: 01/10/2023]
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12
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Sugar or salt? The relative roles of the glucocorticoid and mineralocorticoid axes in traumatic shock. J Trauma Acute Care Surg 2016; 79:1023-9. [PMID: 26680140 DOI: 10.1097/ta.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Glucocorticoid deficiency (GD) has been proposed as a key contributor to shock states, but the presence and role of acute mineralocorticoid deficiency may be of equal or greater significance. We sought to analyze the incidence and degree of acute mineralocorticoid deficiency and GD in an animal model of severe hemorrhage and shock. METHODS Fifty-seven swine underwent 35% volume-controlled hemorrhage followed by aortic cross-clamping for 50 minutes to induce truncal ischemia-reperfusion. Protocol-guided resuscitation was performed. Laboratory analysis included cortisol, aldosterone, and plasma renin activity. The aldosterone-to-renin ratio (ARR) was calculated at each time point, and changes were correlated to markers of perfusion. RESULTS Mean baseline cortisol levels were 5.8 μg/dL. Following hemorrhage, there was a significant increase in mean cortisol to 9.2 μg/dL (p < 0.001). After 1 hour of reperfusion, there was no change in mean cortisol levels (9.8 μg/dL, p = 0.12). Mean baseline aldosterone was 13.3 pg/mL. Aldosterone levels before cross-clamp removal increased significantly to 115.1 pg/mL (p < 0.001) and then rapidly declined to 49.2 pg/mL (p < 0.001) after 1 hour of reperfusion. Conversely, baseline plasma renin activity was 0.75 ng/mL per hour and increased significantly before cross-clamp removal (1.8) and at 1 hour (8.9, both p < 0.001). The ARR at baseline was 96.1 and increased to 113.5 (p = 0.68) before cross-clamp removal but significantly declined following 1 hour of reperfusion to 7.6 (p < 0.001). Overall, this represented a 93% reduction in mean ARR following reperfusion. The degree of aldosterone deficiency correlated with degree of systemic shock as measured by arterial base deficit (r = 0.47, p = 0.04), while cortisol showed no correlation. CONCLUSION Hemorrhagic shock with ischemia-reperfusion injury resulted in only modest impact on the glucocorticoid axis, but major dysfunction of the mineralocorticoid axis and severe hyperreninemic hypoaldosteronism. The degree of aldosterone deficiency may provide prognostic information or offer potential targets for pharmacologic intervention. LEVEL OF EVIDENCE Diagnostic study, level III.
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13
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Annane D. The Role of ACTH and Corticosteroids for Sepsis and Septic Shock: An Update. Front Endocrinol (Lausanne) 2016; 7:70. [PMID: 27379022 PMCID: PMC4913096 DOI: 10.3389/fendo.2016.00070] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/08/2016] [Indexed: 02/05/2023] Open
Abstract
Sepsis is a common disorder associated with high morbidity and mortality. It is now defined as an abnormal host response to infection, resulting in life-threatening dysfunction of organs. There is evidence from in vitro and in vivo experiments in various animal models and in patients that endotoxin or sepsis may directly and indirectly alter the hypothalamic-pituitary-adrenal response to severe infection. These alterations may include necrosis or hemorrhage or inflammatory mediator-mediated decreased ACTH synthesis, steroidogenesis, cortisol delivery to tissues, clearance from plasma, and decreased sensitivity of tissues to cortisol. Disruption of the hypothalamic-pituitary-adrenal axis may translate in patients with sepsis into cardiovascular and other organ dysfunction, and eventually an increase in the risk of death. Exogenous administration of corticosteroids at moderate dose, i.e., <400 mg of hydrocortisone or equivalent for >96 h, may help reversing sepsis-associated shock and organ dysfunction. Corticosteroids may also shorten the duration of stay in the ICU. Except for increased blood glucose and sodium levels, treatment with corticosteroids was rather well tolerated in the context of clinical trials. The benefit of treatment on survival remains controversial. Based on available randomized controlled trials, the likelihood of survival benefit is greater in septic shock versus sepsis patients, in sepsis with acute respiratory distress syndrome or with community-acquired pneumonia versus patients without these conditions, and in patients with a blunted cortisol response to 250 μg of ACTH test versus those with normal response.
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Affiliation(s)
- Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Garches, France
- Laboratory of Infection and Inflammation, U1173, University of Versailles Saint-Quentin-en-Yvelines University, INSERM, Garches, France
- *Correspondence: Djillali Annane,
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Besnier E, Clavier T, Castel H, Gandolfo P, Morin F, Tonon MC, Marguerite C, Veber B, Dureuil B, Compère V. [Interaction between hypnotic agents and the hypothalamic-pituitary-adrenocorticotropic axis during surgery]. ACTA ACUST UNITED AC 2014; 33:256-65. [PMID: 24631003 DOI: 10.1016/j.annfar.2014.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/27/2014] [Indexed: 01/07/2023]
Abstract
During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.
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Affiliation(s)
- E Besnier
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - T Clavier
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - H Castel
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - P Gandolfo
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - F Morin
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - M-C Tonon
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - C Marguerite
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - B Veber
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - B Dureuil
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - V Compère
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France.
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15
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Year in review in Intensive Care Medicine 2012: I. Neurology and neurointensive care, epidemiology and nephrology, biomarkers and inflammation, nutrition, experimentals. Intensive Care Med 2012; 39:232-46. [PMID: 23248038 PMCID: PMC3569582 DOI: 10.1007/s00134-012-2774-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 01/06/2023]
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