Evaluation of Stress-Dose Steroid Weaning Strategies in Patients Following Septic Shock

Abstract

Background:

The 2016 Surviving Sepsis Campaign (SSC) guidelines recommended tapering corticosteroids once vasopressors were no longer needed, while the 2021 update suggested IV hydrocortisone for patients with ongoing vasopressor needs but offered no guidance on tapering. Evidence on steroid taper duration remains limited.

Objective:

This study evaluates corticosteroid tapering strategies in septic shock patients.

Methods:

A retrospective analysis, approved by the UNC Human Research Review Committee, was conducted on adult critically ill patients with septic shock who received vasopressors and hydrocortisone between January 1, 2016, and April 1, 2024. Patients were divided into 2 groups based on the duration of their steroid taper: rapid taper (<72 hours) and prolonged taper (≥72 hours). The primary outcome was vasopressor reinitiation within 72 hours of all vasopressors being stopped. Secondary outcomes included vasopressor reinitiation within 24 hours of all vasopressors being stopped, length of stay (LOS), mortality, and adverse effects. The study was approved by the University of North Carolina Human Research Review Committee.

Results:

A total of 312 patients were analyzed: 222 received a rapid taper and 90 received a prolonged taper. Vasopressor reinitiation within 72 hours occurred in 48% of the rapid taper group and 66% of the prolonged group (P = 0.006). Within 24 hours, reinitiation was 42% in the rapid group versus 56% in the prolonged group (P = 0.039). Mortality was 32% in the rapid group and 41% in the prolonged group (P = 0.185). Mean intensive care unit (ICU) LOS was 215 hours for the rapid group and 418 for the prolonged group (P < 0.001). Mean hospital LOS was 447 hours for the rapid group and 734 for the prolonged group (P < 0.001). Hypernatremia was less frequent in the rapid group (29% vs 47%, P = 0.004). Hyperglycemia was similar between groups (24% vs 21%, P = 0.327). Limitations included the retrospective design and potential for selection bias, temporal bias, and missing or inconsistently documented clinical variables.

Conclusion and Relevance:

Rapid corticosteroid tapering in septic shock patients was associated with a reduced incidence of vasopressor reinitiation, shorter ICU and hospital stay, and a lower incidence of hypernatremia. These findings enhance our understanding of tapering strategies and suggest that rapid tapering (<72 hours) in septic shock may improve patient outcomes, informing future clinical guidelines.