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Sepsis & Septic Shock

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Do We Need to Administer Fludrocortisone in Addition to Hydr... : Critical Care Medicine (

This systematic review and Bayesian network meta-analysis, involving 19 studies and 95,841 patients, assessed hydrocortisone with/without fludrocortisone versus placebo in septic shock. Hydrocortisone plus fludrocortisone was associated with reduced short-term mortality (OR: 0.79; 95% CrI: 0.64-0.99; NNT: 21) compared to placebo, showing potential benefits with minimal adverse events. However, findings suggest cautious interpretation due to low certainty evidence and a broad NNT range, indicating the need for further large-scale RCTs.

Dr Mohammed Zakaria
Ibrahim Ameen

Effectiveness of Fludrocortisone Plus Hydrocortisone Versus Hydrocortisone Alone in Septic Shock: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials | American Journal of Respiratory and Critical Care Medicine | Articles in Press (

In a systematic review and Bayesian network meta-analysis of 17 trials (7,688 patients), fludrocortisone plus hydrocortisone showed a lower risk of all-cause mortality in adult septic shock compared to hydrocortisone alone and placebo/usual care. The combination treatment had a 0.85 relative risk of mortality (moderate-certainty evidence) and was 12% more effective than hydrocortisone alone (low-certainty evidence). The analysis relied mainly on indirect evidence due to limited direct comparisons.

Do you add fludrocortisone to your septic shock patients requiring hydrocortisone?

  • Yes

  • No

Ibrahim Ameen
ي ا

Fludrocortisone Plus Hydrocortisone Versus Hydrocortisone Alone as Adjunctive Therapy in Septic Shock:

A Retrospective Cohort Study" by Lock AE et al., published in the Annals of Pharmacotherapy in 2023, explored whether adding fludrocortisone (FC) to hydrocortisone (HC) would improve the time to septic shock reversal in patients. Conducted as a single-center, retrospective cohort study from March 2017 to May 2020, it included adult ICU patients who received either HC plus FC or HC alone, excluding those with prior corticosteroid use, corticosteroids for other indications, single-dose corticosteroid treatment, or shock due to non-sepsis causes. The primary measure was time to shock reversal, with secondary outcomes including mortality and hyperglycemia rates.

The study found no significant difference in time to shock reversal between the two groups, with 251 patients participating (114 in the HC + FC group and 137 in the HC group). The Cox proportional hazards model did indicate a shorter…

Ibrahim Ameen
ي ا

62-year-old male with history of IgM myeloma with significant extramedullary disease complicated by renal failure, previously on daratumumab and lenalitomide with progression, now status post hyperCVAD. Presented with respiratory distress, neutropenic sepsis, streptococcus agalactiea, oral thrush, and bilateral pulmonary infiltrates. Patient was initially placed on BiPAP but required to be intubated and placed on mechanical ventilation with protective lung strategy 🫁.

Chest x-ray is shown below:

Bronchoscopy was done and BAL was sent for PJP and other tests. There were multiple mucosal white spots scattered in trachea and throughout the bronchial tree bilaterally as shown in these images:

What do you think?


Staphylococcal Scalded Skin Syndrome (SSSS) is a serious skin disorder caused by infection with certain strains of Staphylococcus bacteria. These bacteria release exotoxins, specifically exfoliative toxins, which target the protein desmoglein-1 that helps cells in the outer layer of the skin (the epidermis) stick together. When these toxins disrupt the protein, they cause the skin cells to separate, leading to widespread blistering and the appearance of scalded skin.

The symptoms of SSSS typically begin with fever, irritability, and redness of the skin. The skin then becomes tender and forms fluid-filled blisters, which can easily rupture, leaving areas that look like burns or scalds. It's important to note that the mucous membranes, such as those in the mouth and eyes, are typically not involved in SSSS, which can help differentiate it from other similar-looking conditions.

Noor Shah
Ibrahim Ameen
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