(1489) Steroid Timing for Septic Shock: A Single-Center Experience

Introduction: The Surviving Sepsis Campaign recommends steroids in septic shock. However, it is unknown if steroid timing or vasopressor (VP) dose used when starting steroids matters. We hypothesized that early steroid initiation (≤ 6h from VP start) and, separately, steroid start at higher VP doses (≥0.25 mcg/kg/min norepinephrine equivalents) would be associated with greater VP duration reductions.

Methods: We performed a retrospective study of adults in one hospital (July 2020-November 2022) with septic shock on VPs. We considered two exposures: (1) steroids started early vs later; (2) steroids started on higher vs lower dose VPs. Patient characteristics and VP duration were compared across exposures. Multivariable cox proportional hazards models (death as a competing risk) were used to assess each steroid exposure’s association with VP duration.

Results: Out of 762 patients, 273 (35.8%) received steroids—164 (60.1%) early and 109 (39.9%) later; 114 (52.1%) on higher and 105 (47.9%) on lower VP doses (54 had unknown doses). All patients were of similar age (median 70-72y; none/early/late, p=0.30; none/higher/lower doses, p=0.65) and gender (40.4%-47.6% female; p=0.82; p=0.51). Steroid receivers had higher SOFA scores at VP start (median [IQR] none/early/late: 7 [5,9] vs 8 [6,11] vs 10 [7,12], p< 0.001; none/higher/lower doses: 7 [5,9] vs 10 [8,13] vs 8 [6,11], p< 0.001). Unadjusted VP duration differed by steroid timing (median [IQR], none 40.0 [17.0,95.0] vs early 63.7 [35.9,149.0] vs later 59.7 [37.9,151.0] hours, p< 0.001) and VP dose at steroid start (none 40.0 [17.0,95.0] vs higher 59.6 [37.2,120.5] vs lower 58.1 [37.9,159.4] hours, p< 0.001). After adjustment, VP duration remained greater for patients receiving steroids early (sub hazard ratio for VP discontinuation = 0.75 [95% CI 0.62, 0.90], p=0.002) and later (0.78 [0.62, 0.98], p=0.030) compared to no steroids; similarly, VP durations were longer for steroids started at higher (0.81 [0.65, 1.01], p=0.06) and lower (0.74 [0.60, 0.91], p=0.004) VP doses.

Conclusions: Steroid initiation—both early (vs later) and at higher (vs lower) VP doses—was associated with increased VP duration, contrary to randomized controlled trial findings raising concern for residual confounding. We found no difference in starting steroids earlier or at higher VP doses.