Management patients with a severe burn injury is a long-term process. A severe (major) burn is defined by the American Burn Association using the burn injury severity grading system as ≥ 25% total body surface area (TBSA) for those 10 to 40 years of age (excludes superficial burns, such as sunburn) or ≥ 20 percent TBSA in children under 10 years and adults over 40 years of age and ≥ 10% TBSA full-thickness burns.1 In addition, severe burns include all burns involving eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment, all high-voltage electrical burns, all burn injuries complicated by major trauma or inhalation injury and all burn injuries with serious comorbidities.1
Similar to septic shock, major burn triggers the systemic inflammatory response syndrome and predisposes patients to reduced systemic vascular resistance, hypotension and increased cardiac output.2 The use of corticosteroids in the form of low dose hydrocortisone has been proposed as an adjunctive therapy in clinical trials to reduce mortality, reduce time on vasopressors in patients with septic shock and improve shock reversal.3,4
There is limited information about the impact of hydrocortisone administration on vasopressor-dependent severely burned patients. In a case report published in 2002, a 3-day steroid treatment in a 39-year-old severely burned patient (80% TBSA) with hemodynamic instability and low response to vasopressors for 20 days led to blood pressure normalization without the administration of any vasopressor. In addition, in a study including 14 severely burned patients with septic shock, low-dose hydrocortisone was associated with a significant reduction in norepinephrine dosages in surviving patients in addition to significant reduction in median fluid requirement.5,6 The authors of this study sought to evaluate whether the use of low-dose hydrocortisone administration in vasopressor-dependent severely burned patients with shock would reduce shock duration after severe burn injury.7
The study was a placebo-controlled, double-blind randomized clinical trial performed in a burn intensive care unit in France. A total of 32 patients were initially randomized and only those that met the following inclusion criteria were enrolled: age between 18 and 75 years old, TBSA injury over 30% of the body surface, need for norepinephrine infusion between 24 and 72 hours after the burn injury at a dose > 0.5 μg/kg/min. The authors also sought to perform a subgroup analysis in patients presenting with relative adrenal insufficiency (RAI). A corticotropin test was performed in every patient to identify those presenting with RAI. The follow-up duration was of 9 days. After this follow-up, 27 patients were included in the analysis. A total of 12 patients received hydrocortisone 50mg loading dose followed by 200mg/day in days 1-5, 100 mg on day 6 and 50mg on day 7. Placebo infusions in the form of NaCl 0.9% solution were administered to 15 patients.