Effect of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock.

PURPOSE: Several studies have shown hydrocortisone to be beneficial in the treatment of vasopressor-refractory septic shock, but there are minimal data evaluating the efficacy of this fixed dosing regimen in overweight and obese patients. The purpose of this study was to compare the effects of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock refractory to adequate fluid resuscitation and vasopressor administration. METHODS: In this multicenter, retrospective study, we included adult patients with a confirmed or suspected diagnosis of septic shock who received hydrocortisone (200 mg/day). Patients were divided into 4 study groups based on admission body mass index (BMI; defined as BMI of <25 kg/m2, 25-29.9 kg/m2, 30-34.9 kg/m2, and ≥35 kg/m2). The primary outcomes analyzed were change in norepinephrine equivalent dose requirements and mean arterial pressure (MAP) at 6, 12, and 24 hours after initiating hydrocortisone. RESULTS: Between October 1, 2017, and September 30, 2020, 431 patients were screened of whom 219 met inclusion criteria. Baseline characteristics were comparable among the groups. Mean vasopressor requirements (in µg/min) at 6, 12, and 24 hours were as follows: BMI of <25 kg/m2: 28.8, 24.8, and 20; BMI of 25-29.9 kg/m2: 34.1, 33.5, and 24.8; BMI of 30-34.9 kg/m2: 29.5, 33.5, and 24.8; and BMI of ≥35 kg/m2: 32, 25.7 and, 21.2 (P = 0.75, 0.41, and 0.61, respectively). Mean MAP (in mm Hg) at 6, 12, and 24 hours was as follows: BMI of <25 kg/m2: 73.5, 73.6, and 74; BMI of 25-29.9 kg/m2: 71.6, 73.8, and 71.9; BMI of 30-34.9 kg/m2: 72.2, 70, and 72.7; and BMI of ≥35 kg/m2: 70.7, 73.5, and 71.4 (P = 0.56, 0.15, and 0.62, respectively). CONCLUSION: BMI does not appear to impact the effects of fixed-dose hydrocortisone on vasopressor dose or blood pressure in patients with septic shock. Fixed-dose hydrocortisone should continue to be used for vasopressor-refractory septic shock in obese patients.

Balanced Salt Solutions for Critically Ill Patients: Nonplused and Back to Basics.

OBJECTIVES: The purpose of this article is to summarize the results of major randomized controlled trials (RCTs) comparing clinical outcomes of critically ill patients treated with normal saline (NS) or balanced salt solutions (BSSs), address discordant results of these studies, and provide direction for future investigations. DATA SOURCES: PubMed (2011 to January 2022) with bibliographies of retrieved articles searched for additional articles. STUDY SELECTION AND DATA EXTRACTION: RCTs comparing NS and BSSs in critically ill adult patients. DATA SYNTHESIS: Recently published large RCTs comparing NS with BSSs in heterogeneous populations of intensive care unit patients did not find significant differences in mortality, despite positive findings in some end points in prior RCTs. However, there were a number of methodologic issues common to the RCTs including: varying study designs and end points, clinician discretion for the majority or all treatments other than the primary intervention fluid, heterogeneous patients with varying levels of acuity, and lack of power to investigate potential subgroup differences. In addition, there were problematic issues related to blinding and use of nonstudy fluids. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Intravenous fluids are a mainstay of supportive care for critically ill patients. Similar to the so-called crystalloid-colloid debate, there has been a long-standing debate among critical care clinicians and researchers concerning the preferred crystalloid solution, NS versus one of the available BSSs. CONCLUSIONS: Despite the recent publication of large multicenter RCTs, the preferred resuscitation fluid, NS or a BSS, for critically ill patients is still open for debate, although the available investigations do provide some direction for clinicians and for future investigations.