Updating evidence role corticosteroids severe sepsis septic shock

The benefit of treatment on survival remains controversial.Based on available randomized controlled trials, the likelihood of survival benefit is greater in septic shock versus sepsis patients, in sepsis with acute respiratory distress syndrome or with community-acquired pneumonia versus patients without these conditions, and in patients with a blunted cortisol response to 250 μg of ACTH test versus those with normal response.Similarly, in patients with septic shock, postmortem examination suggested overexpression of IL-1 and TNF in hypothalamic nuclei (20).Different cytokines in different brain regions induce different brain responses.Second, inflammatory mediators released in blood from tissues can reach the portal circulation in the median eminence, located outside the BBB, via the anterior hypophyseal arteries.

These alterations may include necrosis or hemorrhage or inflammatory mediator-mediated decreased ACTH synthesis, steroidogenesis, cortisol delivery to tissues, clearance from plasma, and decreased sensitivity of tissues to cortisol.Corticosteroids may also shorten the duration of stay in the ICU.Except for increased blood glucose and sodium levels, treatment with corticosteroids was rather well tolerated in the context of clinical trials.A correct balance between activation of these systems allows controlling infection while maintaining cardiovascular and metabolic homeostasis.A typical neuroendocrine response to stress includes (i) immediate increased secretion of catecholamines from the sympathetic nervous system and adrenal medulla, release of corticotrophin-releasing hormone (CRH) and vasopressin from parvocellular neurons into the portal circulation, and secretion of oxytocin from the neural lobe of the pituitary, (ii) 5–10 s later, secretion of corticotrophin (ACTH) by anterior pituitary cells, (iii) followed a few seconds later by decreased secretion of pituitary gonadotropins and increased secretion of prolactin and growth hormone (in primates), and of renin and glucagon from the kidneys and pancreas, respectively, and (iv) a few minutes later, increased plasma levels of glucocorticoids and inhibition of gonadal steroids secretion.

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