1217: ABRUPT DISCONTINUATION VERSUS WEANING OF HYDROCORTISONE IN THE TREATMENT OF REFRACTORY SEPTIC SHOCK

Abstract

Introduction: Current guidelines lack guidance on discontinuation of hydrocortisone (HCT) used in the treatment of refractory septic shock, thus discontinuation strategies vary widely in practice. The purpose of this study was to identify the incidence of recurrent shock and the associated safety outcomes when comparing HCT discontinuation strategies used for septic shock. Methods: A retrospective, cohort study was conducted with medical critical care patients grouped based on HCT discontinuation strategy: abrupt discontinuation (discontinuation while dose ≥200 mg/day) and weaning (use of any dose < 200 mg/day). Adult patients with septic shock who received IV HCT at a dose of ≥200 mg/day for ≥48 hours prior to discontinuation or wean were included. The primary outcome was the recurrent shock within 24 hours from HCT discontinuation, defined as restarting vasopressors for at least 2 hours, or, if patients still had vasopressors active at HCT discontinuation, an increase in vasopressors to ≥0.2 mcg/kg/min in norepinephrine equivalents or the addition of another vasopressor. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation, and duration of HCT therapy. Safety outcomes included rates of gastrointestinal bleed, hyperglycemia, and hypertension. Results: A total of 149 patients were included in the analysis: 89 in the abrupt group and 60 in the wean group. All patients received 200-300 mg/day of HCT initially. Both groups had similar durations of HCT therapy prior to their discontinuation/wean. Recurrent septic shock occurred in 6/89 patients (6.7%) in the abrupt discontinuation group and 6/60 patients (10%) in the weaning group (p=0.473). No differences were observed for ICU LOS or duration of mechanical ventilation, but patients in the abrupt group spent fewer total days on any dose of HCT (difference, 3 days, p< 0.001). For safety outcomes, patients in the wean group experienced higher rates of hyperglycemia during their wean compared to patients who had HCT abruptly discontinued (33.3% vs 19.1%, p=0.049); there were no differences in other safety outcomes. Conclusions: Among adults treated with HCT for septic shock, there was no difference in rates of recurrent shock when comparing a weaning strategy to an abrupt discontinuation strategy.