Abrupt Discontinuation Versus Taper of Hydrocortisone in Patients With Septic Shock.

BACKGROUND: Although not mentioned in the most recent guidelines, the 2016 Surviving Sepsis Campaign guidelines recommend to taper corticosteroids once vasopressors are no longer needed; however, at the time of publication, there were no studies comparing taper versus abrupt discontinuation of corticosteroids. OBJECTIVES: The purpose of this study was to further evaluate the impact of abrupt versus taper discontinuation of corticosteroids in septic shock. METHODS: This was a retrospective cohort study that included patients who received an initial dose of 200 to 300 mg of hydrocortisone for septic shock. Participants were then divided into "abrupt" and "taper" groups. The primary outcome assessed was hemodynamic instability during taper or within 72 hours of the last corticosteroid dose. Secondary outcomes included intensive care unit (ICU) and hospital length of stay, incidence of hyperglycemia or hypernatremia, and in-hospital mortality. RESULTS: The primary outcome of reinitiation of vasopressor therapy occurred in a larger proportion of patients in the taper group compared with the abrupt group (21.9% vs 10.7%). The ICU length of stay (7.6 days abrupt vs 9 days taper) and hospital length of stay (14.9 vs 15.3 days) were similar between groups. There was a statistically significant increase in patients who experienced hyperglycemia within 24 hours of the last corticosteroid dose in the abrupt group. All other secondary outcomes were similar between groups. CONCLUSIONS: The abrupt discontinuation of hydrocortisone in the treatment of septic shock was associated with a nonstatistically significant 50% absolute reduction in the need for vasopressor reinitiation.

Atracurium Versus Cisatracurium in the Treatment of Acute Respiratory Distress Syndrome.

Background: Neuromuscular blocking agents are one of the few medication classes that have demonstrated a clinical benefit in patients with severe acute respiratory distress syndrome (ARDS). However, most literature utilized cisatracurium, and utilization of atracurium is limited to 1 small study. Objective: The purpose of this study was to provide further evidence comparing the safety and efficacy of atracurium versus cisatracurium for the treatment of ARDS. Methods: This multicenter, retrospective, observational cohort noninferiority study was conducted at 3 hospitals within a tertiary health care system. We included subjects diagnosed with ARDS who received either atracurium or cisatracurium for at least 12 hours. The primary outcome measured the change in PaO2/FiO2 (P/F) ratio from baseline to 48 hours after initiation. Results: Baseline characteristics were similar between groups except for a higher median age and a higher proportion of subjects who were COVID-positive in the atracurium group. There were also some noted differences in the baseline P/F ratios. In a multivariable model adjusting for baseline characteristics, the change in the P/F ratio for atracurium was noninferior to cisatracurium at 24, 48, and 72 hours. A significant cost reduction, measured as cost per patient per day, was seen with the use of atracurium ($14.81-$25.16 vs $33.86-$41.91). Conclusion: Atracurium appears to be a safe and cheaper alternative agent in the management of ARDS.