In this episode, I’ll discuss how soon hydrocortisone should be added to patients with septic shock.
Back in episode 818, I discussed recently published data that suggested a mortality benefit for adding hydrocortisone to patients on norepinephrine for septic shock rather than adding vasopressin. To add to that data, a group of authors recently published a study in Analgesia and Anesthesia looking at the association between the timing of hydrocortisone administration and mortality in septic shock.
This was a retrospective cohort that looked at both short and long term mortality data based on how long after vasopressors were started was hydrocortisone initiated. Previous studies looked at short term mortality only with conflicting results, so this group of authors included long term mortality as well as short term in an effort to bring clarity to this issue.
Over 800 patients were included in the cohort. Those that received hydrocortisone within 12 hours of starting vasopressors were considered the early group with the late group receiving hydrocortisone 12 or more hours after starting vasopressors.
For the entire cohort, the median time to start hydrocortisone was 7 hours with an intra-quartile range of 2 to 19 hours. About two-thirds of the patients were in the early group. After adjustment for potential confounders, the authors found hydrocortisone initiation 12 or more hours after vasopressors were started was associated with an increased 1-year mortality when compared to the early group with an adjusted hazard ratio of 1.39.
In addition to higher long-term mortality with late hydrocortisone use, this group was also associated with increased 28-day, 90-day, and in-hospital mortality as well as a prolonged length of stay.
Like the study from Episode 818, this one is retrospective in nature and even though attempts were made to control for potential confounders with statistical techniques, there may have been differences between the groups that were not accounted for. It is likely that confirmation of results in a randomized trial will be required before the surviving sepsis guidelines make a strong recommendation with regards to the timing of hydrocortisone initiation.
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