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A steroid combo to beat back septic shock, delirium in COVID-19 patients, and hospital adherence to ventilator standards during the pandemic were examined in studies at the Society of Critical Care Medicine (SCCM) virtual Critical Care Congress.

No One-Two Punch for Septic Shock

A single-center study found that adding fludrocortisone to hydrocortisone did not increase the number of shock-free days in patients with septic shock.

There is controversy over whether to treat these patients with hydrocortisone alone or with add-on fludrocortisone, explained Kayla John, PharmD, of University of North Carolina at Chapel Hill, and studies have found conflicting results in terms of mortality and shock reversal.

John and colleagues conducted a retrospective, propensity score-weighted cohort study that tracked 212 patients, ages 18-89, who were treated in a hospital ICU from 2015-2020 and diagnosed with septic shock. Patients "were included if they received ≥200 mg/day hydrocortisone for at least 24 hours, [with or without] fludrocortisone, initiated within 72 hours of vasopressors," the researchers reported.

Among 111 patients who received hydrocortisone alone and 101 who received hydrocortisone-fludrocortisone, there were no statistically significant differences between shock-free days over 14 days (6.3 days vs 6.1 days, respectively, P=0.781) or in-hospital mortality (46.7% vs 52.2%, respectively, P=0.477). John's group also found no difference in other outcomes such as length of stay in hospital and ICU, duration of shock, and change in Sequential Organ Failure Assessment score.

However, the authors noted that on day 7, there was a significant difference between the two groups in terms of maximum daily vasopressor doses versus days 1-6 (0.00 vs 0.1 NEeq P=0.03).

Still, "These results suggest that the addition of fludrocortisone to hydrocortisone may not shorten the duration of shock, and use of hydrocortisone is adequate," John said, although she added that more research is needed.

Delirium and a COVID-19 Surge

Delirium rates among patients at one ICU grew during the 2020-2021 COVID-19 surge compared to the same period a year earlier, researchers reported.

Kelley Chilson, PsyD, a clinical psychology fellow at Geisinger Medical Center in Danville, Pennsylvania, and colleagues compared ICU delirium rates from November 2020-January 2021 in patients (n=not stated) with COVID-19 and respiratory failure, to the same period in 2019-2020.

The rate of delirium was higher in each month during the COVID-19 surge:

• 52% in November 2020 vs 35% in November 2019
• 59% in December 2020 vs 42% in December 2019
• 69% in January 2021 vs 39% in January 2020

"It is likely that known risk factors for ICU delirium are magnified in patients with COVID-19, including greater illness severity, prolonged illness course and time on mechanical ventilation, heavy sedation use, prolonged immobilization, and isolation from staff and family members due to visitation restrictions," the researchers wrote. "Factors unique to COVID-19 also increase the risk for delirium. These include the systemic inflammatory response linked to COVID-19, the occurrence of thrombotic events and microvascular insults, and multi-organ failure."

A linked higher rates of delirium in patients with COVID-19 to older age and more severe disease.

Better Survival with Ventilator Guidelines?

In the first 14 months of the COVID-19 pandemic, only 50% of 2,021 patients at 55 hospitals in an international registry received treatment with guideline-based ventilation strategies for COVID-19-related acute respiratory distress syndrome (ARDS), researchers reported.

In addition, in the period from February 2020-April 2021, hospitals that were most likely to offer guideline-based care -- specifically, those in the highest quartile by this measure -- had lower mortality rates than those in the lowest quartile (risk-adjusted odds ratio 0.5, 95% CI 0.2-1.1, P=0.06), according to Michael Garcia, MD of Boston Medical Center, and colleagues.

They retrospectively tracked whether patients at hospitals in the received guideline-recommended care, "defined as low tidal volume (low Vt), plateau pressure (Pplat) < 30 cmH2O, and prone position for PaO2:FiO2 ratio (P:F) < 100."

"Given the significant mortality risk associated with COVID-19 ARDS, there is room for improvement in implementation of guideline-recommended ventilator strategies," Garcia's group stated.