Predictors of Response to Corticosteroids in Vasoplegic Shock Following Cardiopulmonary Bypass

Introduction: Use of steroids in the treatment of vasoplegic shock (VS) secondary to cardiopulmonary bypass (CPB) remains controversial and uniform recommendations are yet to be established. The goal of this study is to identify factors that may predict patient response to and guide the use of steroids in treatment of VS secondary to CPB.


Methods: This is a retrospective review of patients admitted to the cardiovascular intensive care unit (ICU) between August 31st, 2021 and August 31st, 2024. Patients included were 18 years and older, underwent cardiac surgery requiring CPB, and received at least 24 hours of 150 mg or greater total hydrocortisone (HCT) dose within 48 hours post-CPB for attenuation of VS. Patients were excluded if there was documentation of chronic steroid use in the last 6 months or acute steroid therapy at a duration of 2 weeks or longer within 4 weeks of encounter, underwent solid organ transplantation, or received methylene blue or hydroxocobalamin post-CPB.

A univariate analysis comparing responders to non-responders to corticosteroid therapy was performed utilizing baseline population, ICU LOS and mortality, hospital LOS and mortality, and hemodynamic outcomes (vasopressor requirements, MAP, SVR). A multivariable logistic regression was performed in a stepwise approach to evaluate predictors of hemodynamic response to steroid therapy.


Results: A total of 322 patients who received HCT were included. Of the total population, 34% of patients (n = 109) were responders to HCT. The median vasopressor requirements at HCT initiation were 11.6 mcg/min NEE and were similar between groups of responders and non-responders. Vasopressor requirements at 6 hours post-HCT initiation were higher in the non-responders group compared to the responders group (12.1 NEE, 6.0 NEE, p < 0.001). MAP at HCT initiation was lower in the non-responders group compared to the responders group (67.5 mmHg, 76.0 mmHg, p < 0.04). Receipt of etomidate was the only predictor associated with HCT therapy response. Receipt of etomidate was associated with nonresponse to HCT therapy for VS (0.727 [0.551, 0.959]).


Conclusions: Hydrocortisone demonstrated varied clinical response when used for VS secondary to CPB. Receipt of etomidate within 48 hours prior to HCT initiation for treatment of VS was associated with nonresponse.