Glucocorticoid administration in sepsis and septic shock: time for a paradigm change?

The use of corticosteroids in patients with septic shock remains controversial. Questions remain regarding the more appropriate dose, the optimal timing to initiate therapy, the selection of patients who will benefit most from the treatment and the exact mechanisms involved in their effectiveness. Recent studies have highlighted that, in critically ill patients, corticosteroid metabolism was reduced and associated with high circulating cortisol levels. Hence the required doses of hydrocortisone may be lower than the currently recommended doses in septic shock (i.e. 200 mg/day). However, altered expression and/or function of corticosteroid receptors may still suggest that higher hydrocortisone doses are necessary to overcome this so-called "steroid-resistance". In this article, we summarized these recent concepts and discussed how they could influence the administration of corticosteroids in such patients.