Steroids in sepsis, … etomidate, … Pearl Harbor, … what’s the connection? Well, there is one, and it is relevant to the practice of emergency medicine.

Steroids have enjoyed mixed fortunes as part of the treatment for sepsis and multiple organ failure. When it was realised that an excessive inflammatory response was part of the pathogenesis of sepsis and multiple organ failure high-dose steroids seemed to have much to offer. Initial studies were encouraging.1 But then larger studies failed to show benefit and steroids fell out of favour.2 3 Things changed with increasing interest in the concept of adrenocortical failure or adrenocortical insufficiency in the critically ill.4 Low-dose, or physiological doses of steroids then came under scrutiny as an adjunct to treatment for severe sepsis and septic shock. The publication of a large randomised controlled trial5 and two meta-analyses, which suggested a survival benefit6 7 resulted in steroids being incorporated into the Surviving Sepsis Campaign guidelines.8

Despite this evidence some controversy remained. In the study by Annane et al5 fludrocortisone was given in addition to hydrocortisone for its mineralocorticoid activity. The use of fludrocortisone was not, however, included in the Surviving Sepsis Campaign guidelines.8 Also the study by Annane et al5 showed no benefit in those patients who had a normal or “adequate” cortisol response to a short corticotropin stimulation test.

The Corticosteroid Therapy of Septic Shock (CORTICUS) study, which was published earlier this year, aimed to resolve some of this controversy.9 In this multicentre, …