Hydrocortisone in Vasodilatory Shock

Vasodilatory shock is the most common type of circulatory shock in critically ill patients; sepsis the predominant cause. Steroid use in septic shock gained favor in the 1970s; however, studies of high-dose steroids demonstrated excess morbidity and mortality. Lower dosage steroid use was driven by trials demonstrating improved hemodynamic status and the possibility of relative adrenal insufficiency; however, divergent results led to uncertainty about hydrocortisone treatment. Two recent trials are likely to reinforce the role of steroids in septic shock and change the recommendation in future clinical practice guidelines. Future work could include elucidating mechanisms of shock reversal, interaction of hydrocortisone with other agents, identifying steroid responsiveness using biochemical or gene signatures, and clarifying the role of fludrocortisone.