Abstract
BackgroundMultiple corticosteroids and treatment regimens have been used as adjuncts in the treatment of septic shock. Qualitative and quantitative differences exist at cellular and tissular levels between the different drugs and their patterns of delivery. The objective of this study was to elucidate any differences between the drugs and their treatment regimens regarding outcomes for corticosteroid use in adult patients with septic shock.MethodsNetwork meta-analysis of the data used for the recently conducted Cochrane review was performed. Studies that included children and were designed to assess respiratory function in pneumonia and acute respiratory distress syndrome, as well as cross-over studies, were excluded. Network plots were created for each outcome, and all analyses were conducted using a frequentist approach assuming a random-effects model.ResultsComplete data from 22 studies and partial data from 1 study were included. Network meta-analysis provided no clear evidence that any intervention or treatment regimen is better than any other across the spectrum of outcomes. There was strong evidence of differential efficacy in only one area: shock reversal. Hydrocortisone boluses and infusions were more likely than methylprednisolone boluses and placebo to result in shock reversal.ConclusionsThere was no clear evidence that any one corticosteroid drug or treatment regimen is more likely to be effective in reducing mortality or reducing the incidence of gastrointestinal bleeding or superinfection in septic shock. Hydrocortisone delivered as a bolus or as an infusion was more likely than placebo and methylprednisolone to result in shock reversal.
Highlights
Multiple corticosteroids and treatment regimens have been used as adjuncts in the treatment of septic shock
The results suggest that infusions of hydrocortisone might increase the risk compared with boluses of dexamethasone and compared with boluses of hydrocortisone
There have been three indications for the use of glucocorticoids in sepsis over the last century. They were given as immunosuppressants; large doses of glucocorticoids that have significant immune effects such as dexamethasone and methylprednisolone were given until studies in the late 1980s [23,24,25,26,27] showed a trend towards increased rates of
Summary
Multiple corticosteroids and treatment regimens have been used as adjuncts in the treatment of septic shock. The objective of this study was to elucidate any differences between the drugs and their treatment regimens regarding outcomes for corticosteroid use in adult patients with septic shock. These questions have been investigated primarily in those patients with septic shock, and sufficient studies have been conducted to allow multiple meta-analyses [2,3,4], including a recently updated. This, tied with the evidence that endogenous glucocorticoids are secreted in a pulsatile manner in health [6], major surgery [7] and critical illness [8] warranted further analysis of the effects of the individual drugs and the dose regimens used. We performed a network meta-analysis (NMA) on the data used for the Cochrane review to establish the likely effectiveness of each drug and therapeutic regimen in adults with septic shock
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