SlideShare a Scribd company logo
1 of 15
Download to read offline
CORTICUS
OVMC LANDMARK TRIALS SERIES
Sprung CL, et al. "Hydrocortisone therapy for patients
with septic shock". New England Journal of Medicine.
2008. 358(2):111-24.
Corticosteroid Therapy of Septic Shock (CORTICUS)
Summarized by Isabella Lai, MD; Laxmi Suthar, MD
BACKGROUND
 Severe sepsis is major cause of mortality/morbidity
 Septic shock is most severe manifestation (occurs in 2-
20% of hospitalized patients)
 Steroid use has been controversial
 Prior to CORTICUS, trials (eg Annane Trial, 2002)
showed benefit from hydrocortisone and
fludrocortisone in septic shock and patients with
relative adrenal insufficiency
 Subsequent studies were not able to replicate Annane
Trial and even showed harm (related to infection) when
hydrocortisone was given
 Hydrocortisone has both glucocorticoid and
mineralocorticoid activity.
CLINICAL QUESTION
 Does low dose hydrocortisone therapy
improve survival in critically ill, septic
shock patients?
DESIGN
 Trial Design: Multicenter, double-blind, parallel-group, randomized, placebo-controlled trial
 N=499
 Hydrocortisone (n=251)
 Placebo (n=248)
 Mean follow-up: 28 days
 Primary Outcome: rate of death at 28 days in patients who did not have a response to corticotropin
 Secondary Outcomes: rate of death at 28 days who had response to corticotropin; rate of death in
ICU/hospital/ rate of death at 1 year after randomization; reversal of organ failure
POPULATION
Inclusion Criteria
 Patients 18 years and older
 All patients hospitalized in ICU
 Septic shock within the past 72h (as defined by
sBP <90 despite IV fluid resuscitation OR need
for vasopressors >1h) and hypoperfusion or
organ dysfunction attributable to sepsis
Exclusion Criteria
 Underlying disease with poor prognosis
 Life expectancy <24h
 Immunosuppression
 Treatment with long-term corticosteroids
within past 6 months or short-term
corticosteroids within past 4 weeks
INTERVENTIONS
 Participants randomly assigned to:
 Hydrocortisone 50mg IV q6hour, tapered over 6 days
 Placebo IV q 6 h, tapered over 6 days
 Randomization: Concealed from investigators
 High dose of (250mcg) ACTH-stimulation test was performed 60 minutes prior to admin of meds
 Patients were classified as responsive (cortisol increase >9 mcg/dL) or non-responsive to ACTH
(cortisol increase ≤9 mcg/dL)
CRITICISMS/LIMITATIONS/FUNDING
 The trial was underpowered (needed enrollment of 800 to detect 10% decrease in mortality)
 Patient population was less ill than patients enrolled in prior trials of corticosteroids in shock
 Inclusion criteria of 72 hours may have missed the optimal window of opportunity
 No studies on myopathy induced in patients by hydrocortisone
 Post-hoc analysis showed appropriate antibiotics in 72% vs. 78%, outcomes reported as NSS; this means that one-
quarter of patients did not receive appropriate antibiotics
FUNDING:
European Commission
European Society of Intensive Care Medicine
European Critical Care Research Network
International Sepsis Forum
Gorham Foundation
BOTTOM LINE
Hydrocortisone hastens the reversal of shock IN WHOM shock was reversed
BUT does not confer a survival benefit among patients with septic shock.
Based on CORTICUS and selected other studies, corticosteroids should not be routinely used in
adult patients with septic shock. NEVERTHELESS, there may be a benefit among selected patients.
Blood pressure is dropping,
patient already on 3 pressors…
Should we start
Steroids?
SURVIVING SEPSIS CAMPAIGN
Guidelines for Severe Sepsis and Septic Shock
 If unable to reverse hemodynamic instability with fluid resuscitation and pressors, then
Hydrocortisone 200mg IV daily can be used
 Recommend against ACTH stimulation test in adults with septic shock (Grade 2B)
 Recommend against using hydrocortisone when vasopressors aren’t required (Grade 2D)
 Recommend against using corticosteroids in sepsis without shock (Grade 1D)
DISCUSSION QUESTIONS
 Based on the CORTICUS trial, should hydrocortisone be given in patients with septic shock?
 What is a criticism for why the CORTICUS trial cannot be extrapolated to all patients with septic
shock?
 When should Hydrocortisone be given in critically ill patients with septic shock?
DISCUSSION QUESTIONS
 Based on the CORTICUS trial, should hydrocortisone be given in patients with septic shock?
 ANSWER: Yes, with the understanding that Hydrocortisone can reverse shock, but not improve survival.
 What is a criticism for why the CORTICUS trial cannot be extrapolated to all patients with septic
shock?
 ANSWER: The patients in the CORTICUS trial were not as sick as prior trials. Also, 72 hour window may have
missed optimal window for medication.
 When should Hydrocortisone be given in critically ill patients with septic shock?
 ANSWER: When fluids and vasopressors cannot achieve hemodynamic stability and patient is in persistent
shock
BOARD-LIKE QUESTION
72yo F, admitted to ICU for CAP complicated by
septic shock. Within past 24 hours, patient no
longer requires Levophed to maintain blood
pressure. He is currently receive 100cc/hr of IVNS.
Net fluid balance since admission is 10L. Currently,
he is receiving CTX, Azithromycin, and
Dexmedetomidine.
On PE, T 36.8, HR 78, BP 94/55.
Labs: K 4, Creatinine 2.2
ABG 7.31/51/87
ADAPTED FROM MKSAP 17
QUESTION
Which is the most appropriate next step in
treatment?
A. Give 500cc mL of 12.5% albumin q6hour
B. Start hemodialysis
C. Start hydrocortisone
D. Discontinue IVNS
BOARD-LIKE QUESTION
Educational Objective:
Septic Shock and AKI
Key Point:
In patients with septic shock, aggressive fluid
resuscitation is known to be beneficial only during
early period (within first several hours).
After initial period, fluids unlikely to make kidneys
better (and may worsen it). Can trial d/c IV fluids
and start diuretics.
Albumin can cause harm during recovery phase,
hemodialysis currently not indicated.
Hydrocortisone has not consistently shown benefit.
Additionally, this patient is able to maintain BP
without pressors so hydrocortisone should not be
used.
ANSWER
Which is the most appropriate next step in
treatment?
A. Give 500cc mL of 12.5% albumin q6hour
B. Start hemodialysis
C. Start hydrocortisone
D. Discontinue IVNS
REFERENCES
 Intensive versus conventional glucose control in critically ill patients (2009). New England Journal of
Medicine, 360(13), 1283–1297. doi:10.1056/nejmoa0810
 Brain, P. CORTICUS. Retrieved March 5, 2017, from https://www.wikijournalclub.org/wiki/CORTICUS
625

More Related Content

What's hot

Opportunities for Immune Therapy and Prevention
Opportunities for Immune Therapy and PreventionOpportunities for Immune Therapy and Prevention
Opportunities for Immune Therapy and Preventionbkling
 
Journal club 26- 5-2017
Journal club 26- 5-2017Journal club 26- 5-2017
Journal club 26- 5-2017Amit Verma
 
CAN WE MARCH WITH MARCH META-ANALYSIS?
CAN WE MARCH WITH MARCH META-ANALYSIS?CAN WE MARCH WITH MARCH META-ANALYSIS?
CAN WE MARCH WITH MARCH META-ANALYSIS?Kanhu Charan
 
The Role of Surgery in Metastatic Breast Cancer (MBC)
The Role of Surgery in Metastatic Breast Cancer (MBC)The Role of Surgery in Metastatic Breast Cancer (MBC)
The Role of Surgery in Metastatic Breast Cancer (MBC)Dana-Farber Cancer Institute
 
MANAGEMENT OF METASTASIS RENAL CELL CARCINOMA
MANAGEMENT OF METASTASIS RENAL CELL CARCINOMAMANAGEMENT OF METASTASIS RENAL CELL CARCINOMA
MANAGEMENT OF METASTASIS RENAL CELL CARCINOMAGovtRoyapettahHospit
 
Management of Low Grade Glioma
Management of Low Grade GliomaManagement of Low Grade Glioma
Management of Low Grade GliomaShreya Singh
 
Management of recurrent Glioblastoma and role of Bevacizumab
Management of recurrent Glioblastoma and role of BevacizumabManagement of recurrent Glioblastoma and role of Bevacizumab
Management of recurrent Glioblastoma and role of BevacizumabAjeet Gandhi
 

What's hot (20)

Opportunities for Immune Therapy and Prevention
Opportunities for Immune Therapy and PreventionOpportunities for Immune Therapy and Prevention
Opportunities for Immune Therapy and Prevention
 
8 astha sharma journal club presentation
8 astha sharma journal club presentation8 astha sharma journal club presentation
8 astha sharma journal club presentation
 
Journal club 26- 5-2017
Journal club 26- 5-2017Journal club 26- 5-2017
Journal club 26- 5-2017
 
Journal club: Is Early Dialysis Better?
Journal club: Is Early Dialysis Better?Journal club: Is Early Dialysis Better?
Journal club: Is Early Dialysis Better?
 
PCSK9 Inhibitors
PCSK9 InhibitorsPCSK9 Inhibitors
PCSK9 Inhibitors
 
Journal club 1
Journal club 1Journal club 1
Journal club 1
 
EMPA-KIDNEY.pptx
EMPA-KIDNEY.pptxEMPA-KIDNEY.pptx
EMPA-KIDNEY.pptx
 
Journal club 17
Journal club 17Journal club 17
Journal club 17
 
Atach 2
Atach 2Atach 2
Atach 2
 
Gliadel wafer for GBM
Gliadel wafer for GBMGliadel wafer for GBM
Gliadel wafer for GBM
 
CAN WE MARCH WITH MARCH META-ANALYSIS?
CAN WE MARCH WITH MARCH META-ANALYSIS?CAN WE MARCH WITH MARCH META-ANALYSIS?
CAN WE MARCH WITH MARCH META-ANALYSIS?
 
The Role of Surgery in Metastatic Breast Cancer (MBC)
The Role of Surgery in Metastatic Breast Cancer (MBC)The Role of Surgery in Metastatic Breast Cancer (MBC)
The Role of Surgery in Metastatic Breast Cancer (MBC)
 
MANAGEMENT OF METASTASIS RENAL CELL CARCINOMA
MANAGEMENT OF METASTASIS RENAL CELL CARCINOMAMANAGEMENT OF METASTASIS RENAL CELL CARCINOMA
MANAGEMENT OF METASTASIS RENAL CELL CARCINOMA
 
Landmark trials in carcinoma breast
Landmark trials in carcinoma breastLandmark trials in carcinoma breast
Landmark trials in carcinoma breast
 
M crpc
M crpcM crpc
M crpc
 
Management of Low Grade Glioma
Management of Low Grade GliomaManagement of Low Grade Glioma
Management of Low Grade Glioma
 
Rivur trial
Rivur trialRivur trial
Rivur trial
 
Management of recurrent Glioblastoma and role of Bevacizumab
Management of recurrent Glioblastoma and role of BevacizumabManagement of recurrent Glioblastoma and role of Bevacizumab
Management of recurrent Glioblastoma and role of Bevacizumab
 
11 deepa-khanal journal club presentation
11 deepa-khanal journal club presentation11 deepa-khanal journal club presentation
11 deepa-khanal journal club presentation
 
Radiosurgery For Brain Metastases !
Radiosurgery For Brain Metastases !Radiosurgery For Brain Metastases !
Radiosurgery For Brain Metastases !
 

Viewers also liked (10)

ATN
ATNATN
ATN
 
CYCLOPS
CYCLOPSCYCLOPS
CYCLOPS
 
ACT
ACTACT
ACT
 
SPARCL
SPARCLSPARCL
SPARCL
 
Ephesus
EphesusEphesus
Ephesus
 
Affirm Trial
Affirm TrialAffirm Trial
Affirm Trial
 
Nice-Sugar
Nice-SugarNice-Sugar
Nice-Sugar
 
Courage Trial
Courage TrialCourage Trial
Courage Trial
 
Jupiter Trial
Jupiter TrialJupiter Trial
Jupiter Trial
 
STOPAH
STOPAHSTOPAH
STOPAH
 

Similar to CORTICUS

Severe Sepsis & Septic Shock
Severe Sepsis & Septic ShockSevere Sepsis & Septic Shock
Severe Sepsis & Septic ShockAndrew Ferguson
 
IV%20FLUIDS.pptx
IV%20FLUIDS.pptxIV%20FLUIDS.pptx
IV%20FLUIDS.pptxArunHM3
 
Effect of hydrocortisone on development of shock among
Effect of hydrocortisone on development of shock amongEffect of hydrocortisone on development of shock among
Effect of hydrocortisone on development of shock amongDr fakhir Raza
 
Copy (2) of sepsis present เซกา revised
Copy (2) of sepsis present เซกา revisedCopy (2) of sepsis present เซกา revised
Copy (2) of sepsis present เซกา revisedKit GenSx
 
sepsis 2019.pdf
sepsis 2019.pdfsepsis 2019.pdf
sepsis 2019.pdfzahid aziz
 
Management of severe sepsis & septic shock f
Management of severe sepsis & septic shock  fManagement of severe sepsis & septic shock  f
Management of severe sepsis & septic shock fDMCH
 
Surviving sepsis Guidelines 2012
Surviving sepsis Guidelines 2012Surviving sepsis Guidelines 2012
Surviving sepsis Guidelines 2012Sourabh Pathak
 
Surviving Sepsis Guidelines 2012
Surviving Sepsis Guidelines 2012Surviving Sepsis Guidelines 2012
Surviving Sepsis Guidelines 2012Sun Yai-Cheng
 
Corticosteroids in Sepsis. a pro/con debate 2019
Corticosteroids in Sepsis. a pro/con debate 2019Corticosteroids in Sepsis. a pro/con debate 2019
Corticosteroids in Sepsis. a pro/con debate 2019Mohamed Metwally
 
Management of sepsis
Management of sepsis Management of sepsis
Management of sepsis Ankur Gupta
 
Evidence basedcritcare06
Evidence basedcritcare06Evidence basedcritcare06
Evidence basedcritcare06Hayk Antonyan
 

Similar to CORTICUS (20)

Sepsis
SepsisSepsis
Sepsis
 
Sepsis 3
Sepsis 3Sepsis 3
Sepsis 3
 
CME: Management of Severe Sepsis & Septic Shock
CME: Management of Severe Sepsis & Septic ShockCME: Management of Severe Sepsis & Septic Shock
CME: Management of Severe Sepsis & Septic Shock
 
Severe Sepsis & Septic Shock
Severe Sepsis & Septic ShockSevere Sepsis & Septic Shock
Severe Sepsis & Septic Shock
 
IV%20FLUIDS.pptx
IV%20FLUIDS.pptxIV%20FLUIDS.pptx
IV%20FLUIDS.pptx
 
Effect of hydrocortisone on development of shock among
Effect of hydrocortisone on development of shock amongEffect of hydrocortisone on development of shock among
Effect of hydrocortisone on development of shock among
 
Copy (2) of sepsis present เซกา revised
Copy (2) of sepsis present เซกา revisedCopy (2) of sepsis present เซกา revised
Copy (2) of sepsis present เซกา revised
 
sepsis 2019.pdf
sepsis 2019.pdfsepsis 2019.pdf
sepsis 2019.pdf
 
(Corticus)
(Corticus)(Corticus)
(Corticus)
 
Management of severe sepsis & septic shock f
Management of severe sepsis & septic shock  fManagement of severe sepsis & septic shock  f
Management of severe sepsis & septic shock f
 
Surviving sepsis Guidelines 2012
Surviving sepsis Guidelines 2012Surviving sepsis Guidelines 2012
Surviving sepsis Guidelines 2012
 
Surviving Sepsis Guidelines 2012
Surviving Sepsis Guidelines 2012Surviving Sepsis Guidelines 2012
Surviving Sepsis Guidelines 2012
 
Sepsis guidlines
Sepsis guidlinesSepsis guidlines
Sepsis guidlines
 
Corticosteroids in Sepsis. a pro/con debate 2019
Corticosteroids in Sepsis. a pro/con debate 2019Corticosteroids in Sepsis. a pro/con debate 2019
Corticosteroids in Sepsis. a pro/con debate 2019
 
Bundle of sepsis
Bundle of sepsisBundle of sepsis
Bundle of sepsis
 
Management of sepsis
Management of sepsis Management of sepsis
Management of sepsis
 
Management of Sepsis
Management of SepsisManagement of Sepsis
Management of Sepsis
 
Sepsis
SepsisSepsis
Sepsis
 
Sepsis
SepsisSepsis
Sepsis
 
Evidence basedcritcare06
Evidence basedcritcare06Evidence basedcritcare06
Evidence basedcritcare06
 

More from Isabella Nga Lai (13)

UKPDS
UKPDSUKPDS
UKPDS
 
ACCORD
ACCORDACCORD
ACCORD
 
RABBIT 2
RABBIT 2RABBIT 2
RABBIT 2
 
Vancomycin vs Metronidazole in C.Diff
Vancomycin vs Metronidazole in C.DiffVancomycin vs Metronidazole in C.Diff
Vancomycin vs Metronidazole in C.Diff
 
SONIC
SONICSONIC
SONIC
 
Fidaxomicin in cdiff
Fidaxomicin in cdiffFidaxomicin in cdiff
Fidaxomicin in cdiff
 
COLONPREV
COLONPREVCOLONPREV
COLONPREV
 
SALT-E 2
SALT-E 2SALT-E 2
SALT-E 2
 
SALT-E 6
SALT-E 6SALT-E 6
SALT-E 6
 
SALT-E 5
SALT-E 5SALT-E 5
SALT-E 5
 
SALT-E 4
SALT-E 4SALT-E 4
SALT-E 4
 
SALT-E 3
SALT-E 3SALT-E 3
SALT-E 3
 
GI Bleed
GI BleedGI Bleed
GI Bleed
 

Recently uploaded

Philosophy of Education and Educational Philosophy
Philosophy of Education  and Educational PhilosophyPhilosophy of Education  and Educational Philosophy
Philosophy of Education and Educational PhilosophyShuvankar Madhu
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17Celine George
 
Presentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphPresentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphNetziValdelomar1
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxraviapr7
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17Celine George
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesMohammad Hassany
 
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdfP4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdfYu Kanazawa / Osaka University
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17Celine George
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17Celine George
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxheathfieldcps1
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationMJDuyan
 
Practical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxPractical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxKatherine Villaluna
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfTechSoup
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRATanmoy Mishra
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...Nguyen Thanh Tu Collection
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptxmary850239
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxAditiChauhan701637
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxDr. Santhosh Kumar. N
 

Recently uploaded (20)

Philosophy of Education and Educational Philosophy
Philosophy of Education  and Educational PhilosophyPhilosophy of Education  and Educational Philosophy
Philosophy of Education and Educational Philosophy
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17
 
Presentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphPresentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a Paragraph
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptx
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming Classes
 
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdfP4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptx
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive Education
 
Practical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxPractical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptx
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024
 
Prelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quizPrelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quiz
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptx
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptx
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptx
 

CORTICUS

  • 1. CORTICUS OVMC LANDMARK TRIALS SERIES Sprung CL, et al. "Hydrocortisone therapy for patients with septic shock". New England Journal of Medicine. 2008. 358(2):111-24.
  • 2. Corticosteroid Therapy of Septic Shock (CORTICUS) Summarized by Isabella Lai, MD; Laxmi Suthar, MD
  • 3. BACKGROUND  Severe sepsis is major cause of mortality/morbidity  Septic shock is most severe manifestation (occurs in 2- 20% of hospitalized patients)  Steroid use has been controversial  Prior to CORTICUS, trials (eg Annane Trial, 2002) showed benefit from hydrocortisone and fludrocortisone in septic shock and patients with relative adrenal insufficiency  Subsequent studies were not able to replicate Annane Trial and even showed harm (related to infection) when hydrocortisone was given  Hydrocortisone has both glucocorticoid and mineralocorticoid activity.
  • 4. CLINICAL QUESTION  Does low dose hydrocortisone therapy improve survival in critically ill, septic shock patients?
  • 5. DESIGN  Trial Design: Multicenter, double-blind, parallel-group, randomized, placebo-controlled trial  N=499  Hydrocortisone (n=251)  Placebo (n=248)  Mean follow-up: 28 days  Primary Outcome: rate of death at 28 days in patients who did not have a response to corticotropin  Secondary Outcomes: rate of death at 28 days who had response to corticotropin; rate of death in ICU/hospital/ rate of death at 1 year after randomization; reversal of organ failure
  • 6. POPULATION Inclusion Criteria  Patients 18 years and older  All patients hospitalized in ICU  Septic shock within the past 72h (as defined by sBP <90 despite IV fluid resuscitation OR need for vasopressors >1h) and hypoperfusion or organ dysfunction attributable to sepsis Exclusion Criteria  Underlying disease with poor prognosis  Life expectancy <24h  Immunosuppression  Treatment with long-term corticosteroids within past 6 months or short-term corticosteroids within past 4 weeks
  • 7. INTERVENTIONS  Participants randomly assigned to:  Hydrocortisone 50mg IV q6hour, tapered over 6 days  Placebo IV q 6 h, tapered over 6 days  Randomization: Concealed from investigators  High dose of (250mcg) ACTH-stimulation test was performed 60 minutes prior to admin of meds  Patients were classified as responsive (cortisol increase >9 mcg/dL) or non-responsive to ACTH (cortisol increase ≤9 mcg/dL)
  • 8. CRITICISMS/LIMITATIONS/FUNDING  The trial was underpowered (needed enrollment of 800 to detect 10% decrease in mortality)  Patient population was less ill than patients enrolled in prior trials of corticosteroids in shock  Inclusion criteria of 72 hours may have missed the optimal window of opportunity  No studies on myopathy induced in patients by hydrocortisone  Post-hoc analysis showed appropriate antibiotics in 72% vs. 78%, outcomes reported as NSS; this means that one- quarter of patients did not receive appropriate antibiotics FUNDING: European Commission European Society of Intensive Care Medicine European Critical Care Research Network International Sepsis Forum Gorham Foundation
  • 9. BOTTOM LINE Hydrocortisone hastens the reversal of shock IN WHOM shock was reversed BUT does not confer a survival benefit among patients with septic shock. Based on CORTICUS and selected other studies, corticosteroids should not be routinely used in adult patients with septic shock. NEVERTHELESS, there may be a benefit among selected patients. Blood pressure is dropping, patient already on 3 pressors… Should we start Steroids?
  • 10. SURVIVING SEPSIS CAMPAIGN Guidelines for Severe Sepsis and Septic Shock  If unable to reverse hemodynamic instability with fluid resuscitation and pressors, then Hydrocortisone 200mg IV daily can be used  Recommend against ACTH stimulation test in adults with septic shock (Grade 2B)  Recommend against using hydrocortisone when vasopressors aren’t required (Grade 2D)  Recommend against using corticosteroids in sepsis without shock (Grade 1D)
  • 11. DISCUSSION QUESTIONS  Based on the CORTICUS trial, should hydrocortisone be given in patients with septic shock?  What is a criticism for why the CORTICUS trial cannot be extrapolated to all patients with septic shock?  When should Hydrocortisone be given in critically ill patients with septic shock?
  • 12. DISCUSSION QUESTIONS  Based on the CORTICUS trial, should hydrocortisone be given in patients with septic shock?  ANSWER: Yes, with the understanding that Hydrocortisone can reverse shock, but not improve survival.  What is a criticism for why the CORTICUS trial cannot be extrapolated to all patients with septic shock?  ANSWER: The patients in the CORTICUS trial were not as sick as prior trials. Also, 72 hour window may have missed optimal window for medication.  When should Hydrocortisone be given in critically ill patients with septic shock?  ANSWER: When fluids and vasopressors cannot achieve hemodynamic stability and patient is in persistent shock
  • 13. BOARD-LIKE QUESTION 72yo F, admitted to ICU for CAP complicated by septic shock. Within past 24 hours, patient no longer requires Levophed to maintain blood pressure. He is currently receive 100cc/hr of IVNS. Net fluid balance since admission is 10L. Currently, he is receiving CTX, Azithromycin, and Dexmedetomidine. On PE, T 36.8, HR 78, BP 94/55. Labs: K 4, Creatinine 2.2 ABG 7.31/51/87 ADAPTED FROM MKSAP 17 QUESTION Which is the most appropriate next step in treatment? A. Give 500cc mL of 12.5% albumin q6hour B. Start hemodialysis C. Start hydrocortisone D. Discontinue IVNS
  • 14. BOARD-LIKE QUESTION Educational Objective: Septic Shock and AKI Key Point: In patients with septic shock, aggressive fluid resuscitation is known to be beneficial only during early period (within first several hours). After initial period, fluids unlikely to make kidneys better (and may worsen it). Can trial d/c IV fluids and start diuretics. Albumin can cause harm during recovery phase, hemodialysis currently not indicated. Hydrocortisone has not consistently shown benefit. Additionally, this patient is able to maintain BP without pressors so hydrocortisone should not be used. ANSWER Which is the most appropriate next step in treatment? A. Give 500cc mL of 12.5% albumin q6hour B. Start hemodialysis C. Start hydrocortisone D. Discontinue IVNS
  • 15. REFERENCES  Intensive versus conventional glucose control in critically ill patients (2009). New England Journal of Medicine, 360(13), 1283–1297. doi:10.1056/nejmoa0810  Brain, P. CORTICUS. Retrieved March 5, 2017, from https://www.wikijournalclub.org/wiki/CORTICUS 625