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Practice Rapid Recommendations

Corticosteroid therapy for sepsis: a clinical practice guideline

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3284 (Published 10 August 2018) Cite this as: BMJ 2018;362:k3284

Population

Recommendation applies to: Recommendation does not apply to: Adults and children Patients with pre-existing adrenal insufficiency Non-infectious causes of shock Neonates Pregnant women Any infectious source Patients with and without shock Intra abdominal infections Pneumonia Anaphylactic Cardiogenic Hypovolaemic People with sepsis SOFA score of at least 2

Comparison

or Corticosteroid therapy No corticosteroid therapy Usual care only Intravenous corticosteroids plus usual care Corticosteroids No corticosteroids Usualcare Usualcare + CCS

More details We suggest corticosteroid therapy rather than no corticosteroid therapy. Either option is reasonable. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours corticosteroids Favours no corticosteroids Evidence quality Events per 1000 people No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

18 fewer Mortality Low More 254 236

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns Short term (28-31 days) Corticosteroids may achieve a small or no reduction in short term mortality

Neuromuscular weakness Low More 303 53 fewer 250

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency Borderline Publication bias No serious concerns Corticosteroids may increase the risk of neuromuscular weakness

Quality of Life None More Unknown

Not reported in any of the included studies

Stroke Very low More 5 10 No important difference

Risk of Bias No serious concerns Imprecision Very serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Whether or not corticosteroids impact the risk of stroke is uncertain

Myocardial infarction Very Low More 30 27 No important difference

Risk of Bias No serious concerns Imprecision Very serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Whether or not corticosteroids impact the risk of myocardial infarction is uncertain
Mean number of days

Length of ICU stay Moderate More 13.1 0.7 fewer 12.4

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Corticosteroids probably achieve a small reduction in the duration of initial stay in an intensive care unit (ICU)

Length of hospital stay Moderate More 32.0 0.7 fewer 31.3

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Corticosteroids probably achieve a small reduction in the duration of hospitalization
See patient decision aids
See all outcomes
Those who place more value on avoiding functional deterioration and maximising quality of life than on avoiding death may be more likely to choose not to use corticosteroids Preferences and values Patients at greatest risk of death (such as those with shock, high qSOFA/SOFA scores) will probably have the greatest reduction in risk of death with corticosteroids Risk of death There are no clear differences in efficacy or adverse effects between different corticosteroids or corticosteroid combinations. Most studies used hydrocortisone Choice of corticosteroid Key practical issues No key practical issues Infusion or intermittent bolus dosing Monitoring for serum sodium, potassium, and glucose Corticosteroids No corticosteroids

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