Background: Previous meta analyses demonstrated that high dose glucoc orticoi ds were not beneficial in sepsis.Recently, lower dose glucocorticoids have been studied. Purpose: To compare recent trials of glucocorticoi...Background: Previous meta analyses demonstrated that high dose glucoc orticoi ds were not beneficial in sepsis.Recently, lower dose glucocorticoids have been studied. Purpose: To compare recent trials of glucocorticoids for sepsis with p revious glucocorticoid trials. Data Sources: Systematic MEDLINE search for studi es published between 1988 and 2003. Study Selection: Randomized,controlled trial s of sepsis that examined the effects of glucocorticoids on survival or vasopres sor requirements. Data Extraction: Two investigators independently collected dat a on patient and study characteristics, treatment interventions, and outcomes. D ata Synthesis: The 5 included trials revealed a consistent and beneficial effect of glucocorticoids on survival (12=0%; relative benefit, 1.23, <<95%CI, 1.01 t o 1.50>>; P=0.036) and shock reversal (12=0%; relative benefit, 1.71 <<CI, 1.29 t o 2.26>>; P< 0.001). These effects were the same regardless of adrenal function. In contrast, 8 trials published before 1989 demonstrated a survival disadvantage with steroid treatment (12=14%; relative benefit, 0.89 <<CI, 0.82 to 0.97>>; P=0 .008). In comparison with the earlier trials, the more recent trials administere d steroids later after patients met enrollment criteria (median, 23 hours vs. < 2 hours; P=0.02), for longer courses (6 days vs. 1 day; P=0.01), and in lower to tal dosages (hydrocort isone equivalents,1209 mg vs. 23 975 mg; P=0.01) to patie nts with higher control group mortality rates (mean, 57%vs. 34%; P=0.06) who w ere more likely to be vasopressor dependent (100%vs. 65%; P=0.03). The relati onship between steroid dose and survival was linear, characterized by benefit at low doses and increasing harm at higher doses (P=0.02). Limitations: We could n ot analyze time related improvements in medical care and potential bias seconda ry to nonreporting of negative study results. Conclusions: Although short course s of high dose glucocorticoids decreased survival during sepsis, a 5-to 7-day course of physiologic hydrocortisone doses with subsequent tapering increases s urvival rate and shock reversal in patients with vasopressor dependent septic shock.展开更多
文摘Background: Previous meta analyses demonstrated that high dose glucoc orticoi ds were not beneficial in sepsis.Recently, lower dose glucocorticoids have been studied. Purpose: To compare recent trials of glucocorticoids for sepsis with p revious glucocorticoid trials. Data Sources: Systematic MEDLINE search for studi es published between 1988 and 2003. Study Selection: Randomized,controlled trial s of sepsis that examined the effects of glucocorticoids on survival or vasopres sor requirements. Data Extraction: Two investigators independently collected dat a on patient and study characteristics, treatment interventions, and outcomes. D ata Synthesis: The 5 included trials revealed a consistent and beneficial effect of glucocorticoids on survival (12=0%; relative benefit, 1.23, <<95%CI, 1.01 t o 1.50>>; P=0.036) and shock reversal (12=0%; relative benefit, 1.71 <<CI, 1.29 t o 2.26>>; P< 0.001). These effects were the same regardless of adrenal function. In contrast, 8 trials published before 1989 demonstrated a survival disadvantage with steroid treatment (12=14%; relative benefit, 0.89 <<CI, 0.82 to 0.97>>; P=0 .008). In comparison with the earlier trials, the more recent trials administere d steroids later after patients met enrollment criteria (median, 23 hours vs. < 2 hours; P=0.02), for longer courses (6 days vs. 1 day; P=0.01), and in lower to tal dosages (hydrocort isone equivalents,1209 mg vs. 23 975 mg; P=0.01) to patie nts with higher control group mortality rates (mean, 57%vs. 34%; P=0.06) who w ere more likely to be vasopressor dependent (100%vs. 65%; P=0.03). The relati onship between steroid dose and survival was linear, characterized by benefit at low doses and increasing harm at higher doses (P=0.02). Limitations: We could n ot analyze time related improvements in medical care and potential bias seconda ry to nonreporting of negative study results. Conclusions: Although short course s of high dose glucocorticoids decreased survival during sepsis, a 5-to 7-day course of physiologic hydrocortisone doses with subsequent tapering increases s urvival rate and shock reversal in patients with vasopressor dependent septic shock.
