1Department of Pharmaceutical Services, Emory University Hospital, Atlanta, GA. 2Mercer University College of Pharmacy and Health Sciences, Atlanta, GA. 3Emory Center for Critical Care, Emory University, Atlanta, GA. 4Department of Surgery, Emory Center for Critical Care, Emory University, Atlanta, GA.
Crit Care Med. 2013 Oct;41(10):2310-7. doi: 10.1097/CCM.0b013e31828cef29.
The Surviving Sepsis Campaign suggests giving hydrocortisone to septic patients only if their "blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy." Because the definition of "poorly responsive" is not provided, the purpose of this study was to identify prescribing triggers for hydrocortisone in septic shock.
Retrospective chart review of patients with septic shock over 17 months, who received hydrocortisone, followed by a survey of all intensivists who attended in the study ICUs to determine whether provider attitudes matched clinical practice.
Eight ICUs in an academic hospital and a hybrid academic/community hospital.
A total of 155 patients with septic shock in whom vasopressors were initiated and hydrocortisone was prescribed.
Ninety-nine patients (64%) were already receiving two vasopressors before hydrocortisone was prescribed. An additional 22 patients were on a single high-dose vasopressor prior to corticosteroid initiation. Of patients who survived to have their hydrocortisone dose changed, 57% had their corticosteroids tapered, whereas 43% were abruptly discontinued. Seventy-six percent of patients were no longer on vasopressors when the first dosing change was made. Twenty-seven out of 36 intensivists (75%) completed the survey. The majority (72%) defined "poorly responsive to vasopressors" as the presence of two vasopressors, and 70% stated that they required patients to be off vasopressors prior to altering the corticosteroid dose.
Significant variability exists when corticosteroids are prescribed for septic shock, with the most common interpretation in our institution of "poorly responsive to fluid resuscitation and vasopressor therapy" being the presence of two vasopressors. The method and timing of corticosteroid discontinuation also differed among providers. Self-described prescribing patterns from intensivists closely matched their actual behavior, suggesting variability is due to differing interpretations of the guidelines themselves, rather than a deficit in knowledge translation.
拯救脓毒症运动建议，只有在败血症患者的“血压对液体复苏和血管加压药治疗反应不佳”的情况下才给予氢化可的松。由于没有提供“反应不佳”的定义，本研究的目的是确定败血症性休克中给予氢化可的松的处方触发因素。
对 17 个月内接受氢化可的松治疗的败血症性休克患者进行回顾性图表审查，然后对所有参加研究 ICU 的重症监护医生进行调查，以确定提供者的态度是否与临床实践相符。
一所学术医院和一所混合学术/社区医院的 8 个 ICU。
共 155 例接受血管加压药治疗并开具氢化可的松的败血症性休克患者。
在开始使用氢化可的松之前，有 99 例患者（64%）已经接受了两种血管加压药。在皮质类固醇开始前，另外 22 例患者接受了单一高剂量血管加压药。在幸存下来改变氢化可的松剂量的患者中，57%的患者皮质类固醇逐渐减少，而 43%的患者突然停止。在第一次剂量调整时，76%的患者不再使用血管加压药。36 名重症监护医生中有 27 名完成了调查。大多数（72%）将“对血管加压药反应不佳”定义为存在两种血管加压药，70%的人表示他们需要患者在改变皮质类固醇剂量之前停止使用血管加压药。
在为败血症性休克开皮质类固醇时存在很大的差异，在我们的机构中，最常见的解释是“对液体复苏和血管加压药治疗反应不佳”，即存在两种血管加压药。皮质类固醇的停药方法和时间也因提供者而异。重症监护医生自我描述的处方模式与他们的实际行为非常吻合，这表明差异是由于对指南本身的不同解释，而不是知识转化的不足。
