| Autor: |
Teja B; Interdepartmental Division of Critical Care Medicine and.; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.; Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada., Berube M; The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts., Pereira TV; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom., Law AC; The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts., Schanock C; Medical College of Wisconsin Libraries, Milwaukee, Wisconsin., Pang B; The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts., Wunsch H; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.; Department of Anesthesiology, Weill Cornell Medicine, New York, New York; and., Walkey AJ; Division of Health Systems Sciences, Medical School, University of Massachusetts, Boston, Massachusetts., Bosch NA; The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts. |
| Abstrakt: |
Rationale: The use of hydrocortisone in adult patients with septic shock is controversial, and the effectiveness of adding fludrocortisone to hydrocortisone remains uncertain. Objectives: To assess the comparative effectiveness and safety of fludrocortisone plus hydrocortisone, hydrocortisone alone, and placebo or usual care in adults with septic shock. Methods: A systematic review and a Bayesian network meta-analysis of peer-reviewed randomized trials were conducted. The primary outcome was all-cause mortality at last follow-up. Treatment effects are presented as relative risks (RRs) with 95% credible intervals (CrIs). Placebo or usual care was the reference treatment. Measurements and Main Results: Among 7,553 references, we included 17 trials (7,688 patients). All-cause mortality at last follow-up was lowest with fludrocortisone plus hydrocortisone (RR, 0.85; 95% CrI, 0.72-0.99; 98.3% probability of superiority, moderate-certainty evidence), followed by hydrocortisone alone (RR, 0.97; 95% CrI, 0.87-1.07; 73.1% probability of superiority, low-certainty evidence). The comparison of fludrocortisone plus hydrocortisone versus hydrocortisone alone was based primarily on indirect evidence (only two trials with direct evidence). Fludrocortisone plus hydrocortisone was associated with a 12% lower risk of all-cause mortality compared with hydrocortisone alone (RR, 0.88; 95% CrI, 0.74-1.03; 94.2% probability of superiority, moderate-certainty evidence). Conclusions: In adult patients with septic shock, fludrocortisone plus hydrocortisone was associated with lower risk of all-cause mortality at last follow-up than placebo and hydrocortisone alone. The scarcity of head-to-head trials comparing fludrocortisone plus hydrocortisone versus hydrocortisone alone led our network meta-analysis to rely primarily on indirect evidence for this comparison. Although we undertook several sensitivity analyses and assessments, these findings should be considered while also acknowledging the heterogeneity of included trials. |
