(1424) Evaluation of Stress-Dose Steroid Tapers in Septic Shock

Introduction: Hydrocortisone is recommended for the treatment of refractory septic shock. Abrupt discontinuation of steroids can lead to withdrawal due to secondary adrenal insufficiency. Treatment durations longer than 10-14 days have been considered high risk. There is no guidance on which patients should receive a steroid taper or how the taper should be accomplished.

Methods: A retrospective single center chart review of adult patients admitted to the emergency department or intensive care unit, with a confirmed diagnosis of septic shock, who received stress dose steroids (hydrocortisone 50 mg IV every 6 hours or 100 mg IV every 8 hours) for at least 24 hours. Data was collected from January 1, 2021, through December 31, 2021. The primary outcome was the percentage of patients who received a steroid taper. Secondary outcomes included duration of stress dose steroid dosing, method of steroid taper (decrease in dose, frequency, or both), duration of taper, and need for increase in vasopressor requirement within the first 48 hours of steroid taper initiation or discontinuation.

Results: One hundred fifty-six patients were included. Patients were initiated on stress dose steroids when 1.8 ± 0.7 vasopressors were being administered, and the mean rate of norepinephrine during this time was 0.27 ± 0.26 mcg/kg/minute. Eighty-six (55.1%) patients received a steroid taper, with the primary method of taper being a decrease in frequency (52.3%). The duration of stress dose steroids regardless of discontinuation strategy was 2.9 ± 4.5 days. This was equivalent to the duration of steroid tapers (2.8 ± 3.2 days). Patients that received a steroid taper were more likely to have an increase in vasopressors at 24 (43% vs. 29%) and 48 hours (20% vs 7%), although this was influenced by a higher ICU mortality rate in the group that did not receive a taper (52% vs. 30%).

Conclusions: Practice variation was revealed regarding initial steroid dosing, as well as decision, method, and duration of taper. Based on risk of secondary adrenal insufficiency, steroid tapers were not needed for a majority of patients in this review. Increases in mortality influenced outcomes, however, this is not indicative of a causal relationship.