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PACULit Literature Updates September 2025: Emergency Medicine & Critical Care

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  1. Use of a drug-related problem oriented medical record in the medication review of critically ill patients Randomized clinical trial
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  2. PACULit Daily Literature Update: Stress hyperglycemia ratio as a biomarker for early mortality risk stratification in cardiovascular disease a propensity matched analysis
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  3. PACULit Daily Literature Update: Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury a retrospective study
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  4. PACULit Daily Literature Update: AsNeeded AlbuterolBudesonide in Mild Asthma
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  5. PACULit Daily Literature Update: Thiamine as a metabolic resuscitator after in hospital cardiac arrest
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  6. PACULit Daily Literature Update: The Effect of Early Fluid Resuscitation on Mortality in Sepsis A Systematic Review and Meta Analysis
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  7. PACULit Daily Literature Update: Inhaled isoflurane for sedation of mechanically ventilated children in intensive care (IsoCOMFORT): a multicentre, randomised, active-control, assessor-masked, non-inferiority phase 3 trial
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  8. PACULit Daily Literature Update: Prevalence risk factors and consequences of early clinical deterioration under noninvasive ventilation in emergency department patients a prospective multicentre observational study of the French IRU Network
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  9. PACULit Daily Literature Update: Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock
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  10. Opportunistic Screening for Atrial Fibrillation With Continuous ECG Monitoring in the Emergency Department
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  11. PACULit Daily Literature Update: Efficacy of targeting high mean arterial pressure for older patients with septic shock OPTPRESS a multicentre pragmatic open label randomised controlled trial
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  12. PACULit Daily Literature Update: Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients
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  13. PACULit Daily Literature Update: Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors related intracerebral hemorrhage in veterans
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  14. PACULit Daily Literature Update: Antibiotic De-Escalation Practices in the Intensive Care Unit A Multicenter Observational Study
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  15. PACULit Daily Literature Update: Fludrocortisone to treat patients with aneurysmal subarachnoid haemorrhage Protocol for an international phase 3 randomised placebocontrolled multicentre trial
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  16. PACULit Daily Literature Update: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest
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  17. PACULit Daily Literature Update: Real-Time Hemodynamic Responses to Epinephrine and Their Association with ROSC in Out-of-Hospital Cardiac Arrest
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  18. Reevaluating bicarbonate therapy in pediatric DKA A propensity scorematched analysis of neurological and respiratory outcomes
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  19. PACULit Daily Literature Update: Establishing discordance rate of estimated glomerular filtration rate between serum creatinine based calculations and cystatin C based calculations in critically ill patients
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  20. Alteplase for Posterior Circulation Ischemic Stroke at 45 to 24 Hours
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  21. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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  22. ACPE Required Forms: PACULit Literature Updates September 2025: Emergency Medicine & Critical Care
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Daily Literature Update

Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock

Gilchrist HE, Roginski M, Esteves A, et al. Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock. Hosp Pharm. 2025 Jul;:00185787251355438-. doi: 00185787251355438. PMID: 40671936

Study Type: Retrospective cohort study

Population: 276 ICU patients with septic shock receiving 6gt;=24 hours hydrocortisone (Jan 2020 – Dec 2023)

Intervention: Stress dose hydrocortisone therapy with or without tapering

Outcomes: Vasopressor rates post-taper, hospital and ICU mortality, ICU length of stay, mechanical ventilation duration

Key Findings

  • 50.4% (139) patients received hydrocortisone taper; median taper duration 2 days (IQR 1 63)
  • Tapering mainly by reducing dosing frequency (56.8% of taper patients)
  • Higher vasopressor rate at 24h post taper start/discontinuation in taper group (37.4% vs 21.3%, P = .004)
  • No significant difference in vasopressor rate at 48h (20.3% vs 12.9%, P = .14)
  • Decreased hospital mortality (OR 0.55; 95% CI, 0.33-0.92) and ICU mortality (OR 0.47; 95% CI, 0.27-0.81) in taper group
  • Increased ICU length of stay (OR 1.04; 95% CI, 1.02-1.06) and mechanical ventilation duration (OR 1.08; 95% CI, 1.03-1.12) with taper

Context & Related Research

  • Systematic review/meta-analysis: Corticosteroids reduce short-term mortality and increase shock reversal but increase hyperglycemia risk (PubMed 38250247)
  • Early vs late hydrocortisone: Early use shortens vasopressor duration, no mortality difference (PubMed 34109850)
  • Abrupt vs taper discontinuation: Abrupt cessation linked to less vasopressor reinitiation, more hyperglycemia with tapering (PubMed 35927963)
  • General corticosteroid risks: Associated with hyperglycemia and neuromuscular weakness; optimal dosing and tapering remains uncertain

Strengths & Limitations

Strengths Limitations
Large patient cohort (N=276) across 4 years Retrospective design with potential confounding
Detailed evaluation of tapering methods and durations Lack of randomized control and potential selection bias
Multiple clinically relevant outcomes assessed Variability in tapering protocols limits generalizability

Clinical Implications & Impact

Pharmacists should recognize the variability in hydrocortisone tapering practices and weigh the short-term hemodynamic risks with longer-term mortality benefits. Given the increased vasopressor need and ICU stay with tapering, careful monitoring and individualized taper strategies are essential. This underscores the need to develop standardized protocols and further prospective research to optimize steroid discontinuation in septic shock management.

Conclusion

Variability in hydrocortisone tapering for septic shock is common; tapering is associated with increased early vasopressor use but decreased hospital and ICU mortality, highlighting the need for further guidelines and research.

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Citations

  • Gilchrist HE et al. Hosp Pharm. 2025 Jul;:00185787251355438-. PMID:40671936
  • Systematic Review et al. PubMed. 2023; PMID:38250247
  • Hydrocortisone Timing Study. PubMed. 2021; PMID:34109850
  • Abrupt vs Taper Corticosteroid Study. PubMed. 2022; PMID:35927963

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