| 성분명 | hydrocortisone sodium succinate |
| 상품명 | 코티소루 주 |
| 함량 | 100 MG |
패혈증 시 hydrocortisone의 투여에 대한 명확한 가이드라인이 부족한 실정임.
일반적으로 hydrocortison의 intermittent infusion, 즉 50 mg q6h regimen이 주로 사용됨.
이번 시간엔 continuous infusion vs. intermittent infusion의 차이에 대해 알아보도록 하자!
[1] Comparison Between Continuous and Intermittent Administration of Hydrocortisone During Septic Shock: A Randomized Controlled Clinical Trial
🌵intervention
| hydrocortisone 200 mg/d by continuous infusion | hydrocortisone 50 mg q6h by boluses |
| 29명 | 29명 |
| throughout the prescription of vasopressors with a maximum of 7 days. | |
🌵result
| bolus infusion | continuous infusion | p | |
| Shock reversal | 66% | 35% | 0.008 |
| Median time to shock reversal | 5 days (95% CI, 4.31–5.69) | 6 days (95% CI, 4.80–7.19) | - |
| The number of hours spent with blood glucose ≥ 180 mg/dL | median of 48 h [IQR (14–107)] | median of 64 h [IQR (2–100)] |
0.60 |
| Daily insulin requirements | similar |
0.63 | |
- BST monitoring 관련한 결과는 제한된 샘플 크기와 영양/칼로리 섭취에 대한 모니터링 부재로 환자들에게 미치는 영향을 정확하게 평가하기 어려움
🌵conclusion
Hydrocortisone administered by intermittent bolus was associated with higher shock reversal at day 7 compared with a continuous infusion.
[2] Impact of bolus application of low-dose hydrocortisone on glycemic control in septic shock patients
🌵intervention
16명의 환자의 다음의 연속적인 처치 ; continuous infusion of hydrocortisone (baseline) → single bolus of 50 mg hydrocortisone q6h , 1시간마다 BST monitoring
🌵result
- bolus infusion 이후 환자별 혈당 수치는 약간 증가 혹은 증가되지 않거나 (n=3). 오히려 감소되는 경우(n=4) 관찰
- 반복적인 hydrocortisone의 intermittent infusion로 혈당 > 150 mg/dL 자주 관찰
🌵conclusion
In conclusion, this observational study demonstrated that a single bolus of 50 mg HC induced a significant increase in blood glucose levels with substantial individual variations in patients with septic shock. In terms of glycemic control strategies, a continuous hydrocortisone application seems to be more practicable in selected patients with septic shock; however, influence on blood glucose variability through bHC administration and the impact on insulin requirements and outcome in patients with septic shock need to be investigated in larger randomized studies.
[3] Corticosteroids in septic shock: a systematic review and network meta-analysis.
🌵mortality up to 28 days(risk of mortality)
- boluses of methylprednisolone > boluses of dexamethasone ; (OR 5.71, 95% CI 0.99–32.9)
- boluses of dexamethasone < placebo (weak evidence) ; (OR 0.25, 95% CI 0.05–1.34)
🌵shock reversal
- boluses of methylprednisolone < boluses of hydrocortisone (strong evidence) ; (OR 0.37, 95% CI 0.19–0.72)
- placebo < boluses of hydrocortisone & infusion of hydrocortisone ; (OR 2.34, 95% CI 0.99–5.50), (OR 3.68, 95% CI 1.52–8.93).
🌵incidence fo superinfections
- boluses of dexamethasone > placebo (weak evidence) ; (OR 2.78, 95% CI 0.73–10.6)
- boluses & continuous infusion of methylprednisolone < boluses of dexamethasone (some evidence) ; 각각 (OR 0.32, 95% CI 0.09–1.19), (0.23, 95% CI 0.05–1.08)
[4] Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
- In the absence of convincing evidence of benefit, we issue a weak recommendation against the use of corticosteroids to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.
- Several randomized trials on the use of low-dose hydrocortisone in septic shock patients revealed a significant increase of hyperglycemia and hypernatremia as side effects.
- Further, considerable inter-individual variability was seen in this blood glucose peak after the hydrocortisone bolus. Although an association of hyperglycemia and hypernatremia with patient outcome measures could not be shown, good practice includes strategies for avoidance and/or detection of these side effects.
- There has been no comparative study between a fixed-duration and clinically guided regimen or between tapering and abrupt cessation of steroids. Three RCTs used a fixed-duration protocol for treatment, and therapy was decreased after shock resolution in two RCTs. In four studies, steroids were tapered over several daysand steroids were withdrawn abruptly in two RCTs. One crossover study showed hemodynamic and immunologic rebound effects after abrupt cessation of corticosteroids. Further, one study revealed no difference in outcome of septic shock patients if low-dose hydrocortisone is used for 3 or 7 days; hence, we suggest tapering steroids when vasopressors are no longer needed.
[5] tapering regimen
1-5일 : hydrocortisone 200 mg/day continuous infusion
6-7일 : hydrocortisone 100 mg/day continuous infusion
8-9일 : hydrocortisone 50 mg/day continuous infusion
10-11일 : hydrocortisone 25 mg/day continuous infusion
* 2일에 걸쳐 50% 감량(center, 과마다 방법이 다를 수 있음!)
reference:
1) Tilouche, Nejla, et al. "Comparison between continuous and intermittent administration of hydrocortisone during septic shock: a randomized controlled clinical trial." Shock 52.5 (2019): 481-486.
2) Weber-Carstens, Steffen, et al. "Impact of bolus application of low-dose hydrocortisone on glycemic control in septic shock patients." Intensive care medicine 33.4 (2007): 730-733.
3) Gibbison, Ben, et al. "Corticosteroids in septic shock: a systematic review and network meta-analysis." Critical Care 21.1 (2017): 1-8.
4) Rhodes, Andrew, et al. "Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016." Intensive care medicine 43.3 (2017): 304-377.
5) Keh, Didier, et al. "Effect of hydrocortisone on development of shock among patients with severe sepsis: the HYPRESS randomized clinical trial." Jama 316.17 (2016): 1775-1785.
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