Do low-dose corticosteroids improve mortality or shock reversal in patients with septic shock? A systematic review and position statement prepared for the American Academy of Emergency Medicine.

BACKGROUND: The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock. METHODS: The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials. RESULTS: Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79-1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07-1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation. CONCLUSIONS: The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population.

The inability of emergency physicians to adequately clinically estimate the underlying hemodynamic profiles of acutely ill patients.

OBJECTIVE: Emergency physicians (EPs) estimate the underlying hemodynamics of acutely ill patients and use them to help both diagnose and formulate a treatment plan. This trial compared the EP clinically derived estimates of cardiac output (CO) and systemic vascular resistance (SVR) to those measured noninvasively. METHODS: Forty acutely ill emergency department patients with a broad range of diagnosis and blood pressure (BP) and pulse were monitored for 2 hours using novel noninvasive finger cuff technology (Nexfin; BMEYE, Amsterdam, The Netherlands). The Nexfin device provides continuous BP monitoring and, from the resulting pulse pressure waveform, calculates beat-to-beat CO and SVR. At baseline assessment and after 2 hours of testing and therapy, treating EPs were asked to estimate the CO and SVR (low, normal, or high), and these were compared with Nexfin measurements. RESULTS: Twenty-five men and 15 women were enrolled with a mean age of 62.2 years (SD, 12.6 years). Eighteen had acute shortness of breath; 11, with probable stroke syndrome; 3, with suspected sepsis; and 8, with a systolic BP greater than 180 or less than 100 mm Hg. Concordance tables showed that there was very little agreement (κ values) between either the compared initial CO (-0.0873) and SVR (-0.0645) or the 2-hour values (-0.0645 and -0.1949, respectively). CONCLUSIONS: Emergency physicians cannot accurately estimate the underlying hemodynamic profiles of acutely ill patients when compared with more objective measurements. This inaccuracy may have important clinical ramifications. Further study is needed to determine how to use these measured continuous CO and SVR monitoring values.

Noninvasive continuous or intermittent blood pressure and heart rate patient monitoring in the ED.

OBJECTIVE: Continuous invasive blood pressure (BP) and heart rate (HR) monitoring in the emergency department (ED) is valuable in managing critically ill patients. Novel noninvasive finger cuff technology allows this same uninterrupted monitoring for almost any individual. This exploratory study compares ED noninvasive continuous to intermittent measurements of these variables. METHODS: A variety of acutely ill ED patients (n = 40) with broad ranges of BP and HR underwent simultaneous monitoring using interval standard automated ED devices and continuous finger cuff technology (Nexfin; Bmeye, Amsterdam, The Netherlands) over a period of 2 hours. At baseline and at 15-minute intervals, simultaneous measurements for BP and HR were recorded and compared. RESULTS: There were 25 men and 15 women enrolled with a mean age of 62.2 years (SD, 12.6). Eighteen had acute dyspnea, 11 with probable stroke syndrome, 3 with suspected sepsis, and 8 with a systolic BP greater than 180 or less than 100 mm Hg. Blood pressure and HR values (n = 344) simultaneously measured by automated ED equipment and the Nexfin finger cuff device were compared. The Pearson correlation coefficients were high, and the Bland-Altman plots showed good agreement between the 2 determinations. CONCLUSION: Continuous BP and HR monitoring measured by the Nexfin finger cuff device in this trial showed reasonable agreement when compared with the intermittent values obtained by automated ED equipment. However, theoretically, noninvasive and continuous monitoring of the BP and HR might better reflect underlying hemodynamics than these same measurements obtained intermittently and, thus, could be important in patient management. More study is needed to determine the optimal method of monitoring these parameters.