Evaluating Alternative Steroid Regimens for Vasopressor Weaning in Patients With Septic Shock

Introduction: The 2021 Surviving Sepsis Guidelines recommend the use of intravenous (IV) hydrocortisone (HC) 200 mg/day in patients that have ongoing vasopressor requirements despite adequate volume resuscitation. In 2023, there was a national shortage of IV HC that led to institutions implementing alternative corticosteroid regimens for patients experiencing septic shock. Due to the limited evidence for alternative steroid regimens in septic shock, the aim of this study was to evaluate if these regimens facilitated similar vasopressor weaning effects when compared to HC.


Methods: A retrospective chart review was completed for patients admitted to either the medical, trauma, or neurosurgical ICU and received steroids for septic shock. Patient records were reviewed from May to August of 2022 and May to August of 2023 for HC and dexamethasone (DEX) respectively. Patients were included if they had a norepinephrine equivalent (NEE) dose at time of steroid initiation of at least 0.1 mcg/kg/min, septic shock documented by ICD-10 code, and steroid administration for at least 48 hours. The primary endpoint was NEE dose at 48 hours.


Results: Of 166 patients reviewed, 73 patients (n=33 HC; n=40 DEX) were included. Patients that were included had a mean SOFA score of 10.8 with a standard deviation (SD) of ±3.1 and baseline NEE dose of 0.28 SD±0.1 mcg/kg/min. Most patients were male (60.2%), admitted to the medical ICU (71.2%), and had pneumonia as the primary source of infection (26%). When comparing NEE at 48 hours, there was no difference in vasopressor weaning (HC -0.21 SD±0.21 mcg/kg/min vs. DEX -0.19 SD±0.15 mcg/kg/min, p=0.9). There was also no statistical difference in time to shock resolution, ICU length of stay, and mortality. There were trends towards DEX worsening time to shock resolution (HC 5.6 SD±4.3 days vs. DEX 8.4 SD±8.4 days, p=0.15) and mortality (HC 21.2% vs. DEX 35%, p=0.3).


Conclusions: DEX was able to demonstrate similar efficacy in vasopressor weaning when compared to HC in septic shock. Future studies are needed to evaluate the trend towards worsened mortality and time to shock resolution with the use of DEX. HC should still be prioritized in septic shock patients for future shortages, but DEX can be considered.