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Ishii J, Ohshimo S, Nishikimi M, Kyo M, Shime N. Complex interaction of infusion volumes and confounding factors with lactate clearance in septic shock. Intensive Care Med 2024:10.1007/s00134-024-07530-4. [PMID: 38990334 DOI: 10.1007/s00134-024-07530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Junki Ishii
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Mitsuaki Nishikimi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Michihito Kyo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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2
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John KE, Kirkpatrick MM, Aytoda PH, Elefritz JL, Palettas M, Rosales BN, Murphy CV, Doepker BA. The effect of hydrocortisone versus hydrocortisone plus fludrocortisone on duration of shock: A propensity score-weighted analysis. Int J Crit Illn Inj Sci 2024; 14:79-85. [PMID: 39005974 PMCID: PMC11245135 DOI: 10.4103/ijciis.ijciis_66_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 07/16/2024] Open
Abstract
Background The 2021 Surviving Sepsis Campaign Guidelines recommend the use of hydrocortisone in patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy. Fludrocortisone has been used concomitantly with hydrocortisone in some studies without a clearly defined role or known clinical benefit. The purpose of this study was to assess the impact of fludrocortisone added to hydrocortisone on shock-free days for septic shock. Methods A single-center, retrospective propensity score-weighted study was conducted to compare hydrocortisone versus hydrocortisone plus fludrocortisone for septic shock. Adults admitted to the medical intensive care unit (ICU) from 2015 to 2020 were included in the study. All patients received ≥200 mg/day hydrocortisone for at least 24 h ± fludrocortisone initiated within 72 h of vasopressors. The primary outcome was shock-free days by day 14. The secondary outcomes included duration of shock, change in Sequential Organ Failure Assessment (SOFA) score, hospital and ICU length of stay, and all-cause inhospital mortality. Results A total of 228 patients met inclusion criteria with 212 patients retained after propensity score weighting. There was no difference between groups in 14-day shock-free days (6.3 vs. 6.1 days; P = 0.781). Furthermore, no significant differences were observed for the secondary outcomes of ICU/hospital length of stay, duration of shock, change in SOFA score, and all-cause inhospital mortality. Conclusion The addition of fludrocortisone to hydrocortisone in septic shock did not increase shock-free days by day 14. These results suggest that the use of hydrocortisone alone may be an adequate adjunctive therapy in septic shock. A prospective randomized controlled trial is needed to confirm results.
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Affiliation(s)
- Kayla E. John
- Department of Pharmacy, The University of North Carolina at Chapel Hill Medical Center, Chapel Hill, NC, USA
| | - Megan M. Kirkpatrick
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Priyanka H. Aytoda
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jessica L. Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marilly Palettas
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Brittany N. Rosales
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Claire V. Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bruce A. Doepker
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Lock AE, Gutierrez GC, Hand EO, Barthol CA, Attridge RL. Fludrocortisone Plus Hydrocortisone Versus Hydrocortisone Alone as Adjunctive Therapy in Septic Shock: A Retrospective Cohort Study. Ann Pharmacother 2023; 57:1375-1388. [PMID: 37026172 DOI: 10.1177/10600280231164210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Trials evaluating hydrocortisone (HC) for septic shock are conflicting with all finding decreased time to shock reversal but few with mortality difference. Those with improved mortality included fludrocortisone (FC), but it is unknown if FC affected the outcome or is coincidental as there are no comparative data. OBJECTIVE The objective of this study was to determine the effectiveness and safety of FC + HC versus HC alone as adjunctive therapy in septic shock. METHODS A single-center, retrospective cohort study was conducted of medical intensive care unit (ICU) patients with septic shock refractory to fluids and vasopressors. Patients receiving FC + HC were compared with those receiving HC. Primary outcome was time to shock reversal. Secondary outcomes included in-hospital, 28-, and 90-day mortality; ICU and hospital length of stay (LOS); and safety. RESULTS There were 251 patients included (FC + HC, n = 114 vs HC, n = 137). There was no difference in time to shock reversal (65.2 vs 71 hours; P = 0.24). Cox proportional hazards model showed time to first corticosteroid dose, full-dose HC duration, and use of FC + HC were associated with shorter shock duration, while time to vasopressor therapy was not. However, in 2 multivariable models controlling for covariates, use of FC + HC was not an independent predictor of shock reversal at greater than 72 hours and in-hospital mortality. No differences were seen in hospital LOS or mortality. Hyperglycemia occurred more frequently with FC + HC (62.3% vs 45.6%; P = 0.01). CONCLUSION AND RELEVANCE FC + HC was not associated with shock reversal at greater than 72 hours or decreased in-hospital mortality. These data may be useful for determining corticosteroid regimen in patients with septic shock refractory to fluids and vasopressors. Future prospective, randomized studies are needed to further evaluate the role of FC in this patient population.
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Affiliation(s)
- Ashley E Lock
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - G Christina Gutierrez
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Elizabeth O Hand
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Colleen A Barthol
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Rebecca L Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
- Department of Medicine, Division of Pulmonary Diseases and Critical Care, UT Health San Antonio, San Antonio, TX, USA
- The Craneware Group, Deerfield Beach, FL, USA
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Zhang L, Gu WJ, Huang T, Lyu J, Yin H. The Timing of Initiating Hydrocortisone and Long-term Mortality in Septic Shock. Anesth Analg 2023; 137:850-858. [PMID: 37171987 DOI: 10.1213/ane.0000000000006516] [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: 05/14/2023]
Abstract
BACKGROUND Previous studies on the association between the timing of corticosteroid administration and mortality in septic shock focused only on short-term mortality and produced conflicting results. We performed a retrospective review of a large administrative database of intensive care unit (ICU) patients to evaluate the association between the timing of hydrocortisone initiation and short- and long-term mortality in septic shock. We hypothesized that a longer duration between the first vasopressor use for sepsis and steroid initiation was associated with increased mortality. METHODS Data were extracted from the Medical Information Mart in the Intensive Care-IV database. We included adults who met Sepsis-3 definition for septic shock and received hydrocortisone. The exposure of interest was the time in hours from vasopressor use to hydrocortisone initiation (>12 as late and ≤12 as early). The primary outcome was 1-year mortality. Secondary outcomes included 28-day mortality, 90-day mortality, in-hospital mortality, and length of hospital stay. Cox proportional hazard models were used to estimate the association between exposure and mortality. Competing risk regression models were used to evaluate the association between exposure and length of hospital stay. RESULTS A total of 844 patients were included in this cohort: 553 in the early group and 291 in the late group. The median time to hydrocortisone initiation was 7 hours (interquartile range, 2.0-19.0 hours). After multivariable Cox proportional hazard analysis, we found that hydrocortisone initiation >12 hours after vasopressor use was associated with increased 1-year mortality when compared with initiation <12 hours (adjusted hazard ratio, 1.39; 95% confidence interval, 1.13-1.71; P = .002, E-value = 2.13). Hydrocortisone initiation >12 hours was also associated with increased 28-day, 90-day, and in-hospital mortality and prolonged length of hospital stay. CONCLUSIONS In patients with septic shock, initiating hydrocortisone >12 hours after vasopressor use was associated with an increased risk of both short-term and long-term mortality, and a prolonged length of hospital stay.
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Affiliation(s)
- Luming Zhang
- From the Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wan-Jie Gu
- From the Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jun Lyu
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
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5
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Suh GJ, shin TG, Kwon WY, Kim K, Jo YH, Choi SH, Chung SP, Kim WY. Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines. Clin Exp Emerg Med 2023; 10:255-264. [PMID: 37439141 PMCID: PMC10579730 DOI: 10.15441/ceem.23.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023] Open
Abstract
Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.
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Affiliation(s)
- Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Tae Gun shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - You Hwan Jo
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - for the Korean Shock Society Investigators
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kulesza S, Gignac L, Colvin CA, Boll S, Giuliano C, Haan B, Allen B, Perez MM, Allen M, Edwin SB. Hydrocortisone versus vasopressin for the management of adult patients with septic shock refractory to norepinephrine: A multicenter retrospective study. Pharmacotherapy 2023; 43:787-794. [PMID: 37148191 DOI: 10.1002/phar.2811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
STUDY OBJECTIVE Significant practice variation exists when selecting between hydrocortisone and vasopressin as second line agents in patients with septic shock in need of escalating doses of norepinephrine. The goal of this study was to assess differences in clinical outcomes between these two agents. DESIGN Multicenter, retrospective, observational study. SETTING Ten Ascension Health hospitals. PATIENTS Adult patients with presumed septic shock receiving norepinephrine prior to study drug initiation between December 2015 and August 2021. INTERVENTION Vasopressin (0.03-0.04 units/min) or hydrocortisone (200-300 mg/day). MEASUREMENTS AND MAIN RESULTS A total of 768 patients were included with a median (interquartile range) SOFA score of 10 (8-13), norepinephrine dose of 0.3 mcg/kg/min (0.1-0.5 mcg/kg/min), and lactate of 3.8 mmol/L (2.4-7.0 mmol/L) at initiation of the study drug. A significant difference in 28-day mortality was noted favoring hydrocortisone as an adjunct to norepinephrine after controlling for potential confounding factors (OR 0.46 [95% CI, 0.32-0.66]); similar results were seen following propensity score matching. Compared to vasopressin, hydrocortisone initiation was also associated with a higher rate of hemodynamic responsiveness (91.9% vs. 68.2%, p < 0.01), improved resolution of shock (68.8% vs. 31.5%, p < 0.01), and reduced recurrence of shock within 72 h (8.7% vs. 20.7%, p < 0.01). CONCLUSIONS Addition of hydrocortisone to norepinephrine was associated with a lower 28-day mortality in patients with septic shock, compared to the addition of vasopressin.
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Affiliation(s)
- Steven Kulesza
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Lindsey Gignac
- Department of Pharmacy, Ascension St Vincent's Riverside Hospital, Jacksonville, Florida, USA
| | - C Allis Colvin
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Skyler Boll
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Bradley Haan
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Bryan Allen
- Department of Pharmacy, Ascension St Vincent's Riverside Hospital, Jacksonville, Florida, USA
| | - Mary M Perez
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Monica Allen
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
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Son JY, Kwack WG, Chung EK, Shin S, Choi YJ. Effects of Early Initiation of High-Dose Dexamethasone Therapy on Pro-Inflammatory Cytokines and Mortality in LPS-Challenged Mice. Healthcare (Basel) 2022; 10:healthcare10071247. [PMID: 35885778 PMCID: PMC9320239 DOI: 10.3390/healthcare10071247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022] Open
Abstract
This study aims to explore the effects of early dexamethasone therapy at low to high doses on the survival and inflammatory responses in lipopolysaccharide (LPS)-challenged mice. We performed two-series experiments to explore the impact of early dexamethasone therapy at different doses (0.5 mg/kg, 1.5 mg/kg, and 5 mg/kg; PO) on pro-inflammatory cytokine levels, including tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), as well as survival in LPS-treated mice (10 mg/kg, IP). Dexamethasone was administered daily from 24 h before and 5 days after LPS challenge. Dose-dependent improved survival was demonstrated with dexamethasone (p < 0.05). Body weight was significantly decreased within 24 h of LPS injection, with significantly greater weight loss in the dexamethasone groups (p < 0.05). Weight changes were significantly associated with the days after LPS administration (p < 0.01), but not with the dexamethasone dose (p > 0.05). Mice treated with high-dose dexamethasone (5 mg/kg) had a significantly lowered serum TNF-α (134.41 ± 15.83 vs. 408.83 ± 18.32) and IL-6 (22.08 ± 4.34 vs. 91.27 ± 8.56) compared with those without dexamethasone. This study provides essential insights that the suppression of early-phase hyperactivation of pro-inflammatory activities through the early initiation of high-dose dexamethasone therapy increases sepsis-related prognosis.
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Affiliation(s)
- Ji-young Son
- Department of Clinical Pharmacy, Graduate School of Pharmacy, CHA University, Seongnam 13488, Korea;
| | - Won Gun Kwack
- Division of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital, Seoul 02447, Korea;
| | - Eun Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
- Correspondence: (E.K.C.); (S.S.); (Y.J.C.); Tel.: +82-2-961-2122 (E.K.C.); +82-31-219-3456 (S.S.); +82-2-961-0532 (Y.J.C.)
| | - Sooyoung Shin
- Department of Clinical Pharmacy, College of Pharmacy, Ajou University, Suwon 16499, Korea
- Research Institute of Pharmaceutical Science and Technology (RIPST), Ajou University, Suwon 16499, Korea
- Correspondence: (E.K.C.); (S.S.); (Y.J.C.); Tel.: +82-2-961-2122 (E.K.C.); +82-31-219-3456 (S.S.); +82-2-961-0532 (Y.J.C.)
| | - Yeo Jin Choi
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02447, Korea
- Correspondence: (E.K.C.); (S.S.); (Y.J.C.); Tel.: +82-2-961-2122 (E.K.C.); +82-31-219-3456 (S.S.); +82-2-961-0532 (Y.J.C.)
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Ragoonanan D, Tran N, Modi V, Morgan Nickelsen P. Unanswered questions on use of hydrocortisone, ascorbic acid, and thiamine therapy in sepsis and septic shock. Am J Health Syst Pharm 2022; 79:1626-1633. [PMID: 35701085 DOI: 10.1093/ajhp/zxac169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To evaluate current evidence on the utility of hydrocortisone, ascorbic acid and thiamine (HAT) therapy for the management of septic shock. SUMMARY The following keyword search terms were utilized in PubMed to identify relevant articles: ascorbic acid, thiamine, hydrocortisone, shock, and critical care. Articles relevant to HAT therapy in patients with septic shock were selected. Retrospective cohorts and randomized controlled trials were included in this review; case reports/series were excluded. Data from included studies illustrating the use of HAT therapy for the management of sepsis and septic shock, including data on time to HAT therapy initiation, severity of illness at baseline, duration of vasopressor therapy, progression of organ failure, and mortality, were evaluated. CONCLUSION The utilization of HAT therapy for the management of sepsis and septic shock remains controversial. Hemodynamic benefits have been shown to be most pronounced when HAT therapy is initiated earlier. Future studies directed at earlier initiation may be necessary to confirm this theory.
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Affiliation(s)
- David Ragoonanan
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Nicolas Tran
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - Veeshal Modi
- Division of Pulmonary/Critical Care, University of South Florida, Tampa, FL, USA
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Ammar MA, Ammar AA, Wieruszewski PM, Bissell BD, T Long M, Albert L, Khanna AK, Sacha GL. Timing of vasoactive agents and corticosteroid initiation in septic shock. Ann Intensive Care 2022; 12:47. [PMID: 35644899 PMCID: PMC9148864 DOI: 10.1186/s13613-022-01021-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/09/2022] [Indexed: 12/20/2022] Open
Abstract
Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.
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Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA.
| | - Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA
| | - Patrick M Wieruszewski
- Departments of Anesthesiology and Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Micah T Long
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI, USA
| | - Lauren Albert
- Department of Pharmacy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Center for Biomedical Informatics, Perioperative Outcomes and Informatics Collaborative, Medical Center Boulevard, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue, Hb-105, Cleveland, OH, USA
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10
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Liang H, Song H, Zhai R, Song G, Li H, Ding X, Kan Q, Sun T. Corticosteroids for Treating Sepsis in Adult Patients: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:709155. [PMID: 34484209 PMCID: PMC8415513 DOI: 10.3389/fimmu.2021.709155] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/26/2021] [Indexed: 12/27/2022] Open
Abstract
Objective Corticosteroids are a common option used in sepsis treatment. However, the efficacy and potential risk of corticosteroids in septic patients have not been well assessed. This review was performed to assess the efficacy and safety of corticosteroids in patients with sepsis. Methods PubMed, Embase, and Cochrane library databases were searched from inception to March 2021. Randomized controlled trials (RCTs) that evaluated the effect of corticosteroids on patients with sepsis were included. The quality of outcomes in the included articles was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation methodology. The data were pooled by using risk ratio (RR) and mean difference (MD). The random-effects model was used to evaluate the pooled MD or RR and 95% confidence intervals (CIs). Results Fifty RCTs that included 12,304 patients with sepsis were identified. Corticosteroids were not associated with the mortality in 28-day (RR, 0.94; 95% CI, 0.87–1.02; evidence rank, moderate) and long-term mortality (>60 days) (RR, 0.96; 95% CI, 0.88–1.05) in patients with sepsis (evidence rank, low). However, corticosteroids may exert a significant effect on the mortality in the intensive care unit (ICU) (RR, 0.9; 95% CI, 0.83–0.97), in-hospital (RR, 0.9; 95% CI, 0.82–0.99; evidence rank, moderate) in patients with sepsis or septic shock (evidence rank, low). Furthermore, corticosteroids probably achieved a tiny reduction in the length of hospital stay and ICU. Corticosteroids were associated with a higher risk of hypernatremia and hyperglycemia; furthermore, they appear to have no significant effect on superinfection and gastroduodenal bleeding. Conclusions Corticosteroids had no significant effect on the 28-day and long-term mortality; however, they decreased the ICU and hospital mortality. The findings suggest that the clinical corticosteroids may be an effective therapy for patients with sepsis during the short time. Systematic Review Registration https://inplasy.com/wp-content/uploads/2021/05/INPLASY-Protocol-1074-4.pdf
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Affiliation(s)
- Huoyan Liang
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Heng Song
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Ruiqing Zhai
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, China
| | - Gaofei Song
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongyi Li
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xianfei Ding
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China
| | - Quancheng Kan
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
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What's New in Shock, April 2021? Shock 2021; 55:419-422. [PMID: 33730006 DOI: 10.1097/shk.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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