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The steroid story: What’s the latest?
Some 40 years ago, high dose steroids were believed to be beneficial in sepsis due to their anti-inflammatory effects. Several years later they fell out of favor as clinical trials failed to demonstrate any benefit. Then the results of the study by Annane et al. in 2002, suggested that moderate-dose steroids may have a role to play, but the results of the multicenter Corticus study published in 2008 again seemed to refute this possibility.
Dr Charles Sprung
So where does that leave the clinician? Should we be using steroids or not, or just in some patients and if so which? In a session on steroids some of the potentially beneficial effects of steroids and some of the likely harmful effects, including an increased risk of superinfections and cytomegalovirus infection were presented. Dr Charles Sprung, leading investigator of the Corticus study, concluded that based on current data and according to current guidelines, steroids should only be used in patients with septic shock who are unresponsive to fluid therapy.
Coagulation and inflammation in sepsis: Proposed therapies
Dr Pierre-François Laterre
Realization of the link between coagulation and inflammation led to the development of activated protein C, a drug that has been shown to reduce mortality rates in patients with severe sepsis and septic shock and is licensed for use in such patients. But activated protein C is expensive and the original study design and results have been criticized. After several talks discussing the links between coagulation and inflammation, Dr Laurent Mosnier presented some insights into the possible mode of action of activated protein C, other than its known anti-coagulant properties. Other speakers then focused on the ongoing debate regarding the use of activated protein C and presented the rationale and design of two ongoing trials. Drs Steven Opal, Pierre-François Laterre and Richard Wunderink then presented the methodology and somewhat disappointing results from a study of tissue factor pathway inhibitor in 2138 patients with severe community-acquired pneumonia, showing that it had no effect on outcomes in these patients. Finally, the present status of antithrombin in patients with sepsis was discussed.
IV fluids: What’s your favorite?
No-one would disagree that intravenous fluids are an essential part of resuscitation in the shocked ICU patient, whatever the cause. But there is considerable disagreement about which fluid and how much fluid to use. In yesterday morning’s session on fluids, Dr Peter Kruger opened with a concise discussion of the basics of fluid distribution and particularly how these may differ in critically ill patients compared to the normal population. Dr Lewis Kaplan then highlighted the potentially detrimental effects of saline resuscitation, including the risks associated with hyperchloremic acidosis. The potential benefits of and indications for hypertonic solutions, albumin, and gelatins were then presented by different speakers. Dr Martin Westphal addressed the idea that hydroxyethyl starch solutions are not nephrotoxic, while Dr Gernot Marx argued that they can damage renal function. More modern hydroxyethyl starch solutions may have a better profile.
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Controversies in renal support
Acute renal failure is a major cause of morbidity in ICU patients and is associated with a higher risk of death. Managing these patients can be difficult and there is considerable debate about optimal extracorporeal strategies, including timing and dose. Dr Carlos Scheinkestel presented the results of the recently completed Australasian multicenter randomized study in which a higher dose strategy (40 ml/kg) of renal replacement was compared to a lower dose (20 ml/kg) in 1508 patients with acute kidney injury. There were no differences between the groups in 90-day mortality rates, ICU length of stay, duration of mechanical ventilation, or development of organ dysfunction.
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ECCRN Research Awards – Deadline 30 April 2009
Visit www.esicm.org >> Research / ECCRN
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