Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock

Introduction: Stress dose hydrocortisone is recommended in septic shock. Discontinuation can lead to withdrawal after prolonged durations of therapy. There is no guidance on the use of steroid tapers. Our objective was to assess prescribing practices and evaluate stress dose hydrocortisone tapers in septic shock. Methods: Retrospective review of patients admitted to the intensive care unit (ICU), with septic shock, who received hydrocortisone for at least 24 hours from January 1, 2020 through December 31, 2023. The primary outcome was the percentage of patients who received a hydrocortisone taper. Secondary outcomes included duration of stress dose hydrocortisone, method and duration of taper, and rate of increased vasopressors at 24 and 48 hours of hydrocortisone taper initiation or discontinuation. Results: Two hundred seventy-six patients were included. The initial duration of hydrocortisone was 2 (1.5-3) days. One hundred thirty-nine (50.4%) patients received a hydrocortisone taper, with a taper duration of 2 (1-3) days. The primary method of taper was a reduction in frequency (56.8%). Patients who received a taper required an increase in vasopressor rate at 24 (37.4% vs 21.3%, P = .004) and 48 hours (20.3% vs 12.9%; P = .14). The steroid taper group showed a decreased hospital (OR 0.55; 95% CI, 0.33-0.92) and ICU mortality rate (OR 0.47; 95% CI, 0.27-0.81), albeit an increased ICU length of stay (OR 1.04; 95% CI, 1.02-1.06), increased duration of mechanical ventilation (OR 1.08; 95% CI, 1.03-1.12), and increased vasopressor rate at 24 hours (OR 2.21; 95% CI, 1.29-3.77). Conclusions: In patients admitted to an ICU for septic shock started on stress dose hydrocortisone there was heterogeneity in the duration of stress dose hydrocortisone and the implementation, method, and length of a taper. This highlights a need for additional attention to methods of discontinuation of stress dose steroids and implications on patient centered outcomes.