Early hydrocortisone ineffective in improving outcomes in patients with septic shock

Reference

Lv QQ, Gu XH, Chen QH, Yu JQ, Zheng RQ. Early initiation of low-dose hydrocortisone treatment for septic shock in adults: A randomized clinical trial. Am J Emerg Med 2017;35(12):1810-1814.

Synopsis

This study included 118 patients with septic shock (hypotension in spite of fluid resuscitation) who were admitted to an intensive care unit (ICU) in a single Chinese hospital. The researchers randomized the patients to receive hydrocortisone or normal saline within 6 hours of admission. The patients also received empiric antibiotics and fluid replacement (20 to 30 mL/kg for 30 to 60 minutes). If the patients were unable to achieve a mean arterial pressure of 65 mm Hg, they also were given vasopressors. In this small study, the patients who received hydrocortisone had higher APACHE II scores and were more likely to have signs of end-organ failure and the placebo-treated patients were more likely to have abdominal infections. Using intention-to-treat analysis, the authors found no statistically significant improvement in 28-day mortality (40% vs 32%), reversal of shock (66% vs 70%), ICU or hospital length of stay or in-hospital mortality. However, they planned their analysis for a much higher mortality rate than what they observed, so this report lacks the power to know for sure that hydrocortisone is ineffective. Finally, the authors re-analyzed their data and found that other factors potentially influenced the study outcomes, further undermining their ability to draw conclusions about the early administration of hydrocortisone. Overcoming the weaknesses of this study would require a large multicenter trial.