Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study.

Antoine Roquilly , Pierre Joachim Mahe , Philippe Seguin (1, 2) , Christophe Guitton (3) , Hervé Floch , Anne Charlotte Tellier , Laurent Merson , Benoît Renard , Yannick Malledant (1, 2) , Laurent Flet , Véronique Sébille (4) , Christelle Volteau , Damien Masson , Jean Michel Nguyen , Corinne Lejus , Karim Asehnoune (5)

1 Service d'anesthésie réanimation chirurgicale [Rennes]
2 Foie, métabolismes et cancer
3 Service de Réanimation Médicale
4 Biostatistique, Recherche Clinique et Mesures Subjectives en Santé
5 Service d'anesthésie et réanimation chirurgicale [Nantes]

CONTEXT: The role of stress-dose hydrocortisone in the management of trauma patients is currently unknown. OBJECTIVE: To test the efficacy of hydrocortisone therapy in trauma patients. DESIGN, SETTING, AND PATIENTS: Multicenter, randomized, double-blind, placebo-controlled HYPOLYTE (Hydrocortisone Polytraumatise) study. From November 2006 to August 2009, 150 patients with severe trauma were included in 7 intensive care units in France. INTERVENTION: Patients were randomly assigned to a continuous intravenous infusion of either hydrocortisone (200 mg/d for 5 days, followed by 100 mg on day 6 and 50 mg on day 7) or placebo. The treatment was stopped if patients had an appropriate adrenal response. MAIN OUTCOME MEASURE: Hospital-acquired pneumonia within 28 days. Secondary outcomes included the duration of mechanical ventilation, hyponatremia, and death. RESULTS: One patient withdrew consent. An intention-to-treat (ITT) analysis included the 149 patients, a modified ITT analysis included 113 patients with corticosteroid insufficiency. In the ITT analysis, 26 of 73 patients (35.6%) treated with hydrocortisone and 39 of 76 patients (51.3%) receiving placebo developed hospital-acquired pneumonia by day 28 (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.30-0.83; P = .007). In the modified ITT analysis, 20 of 56 patients (35.7%) in the hydrocortisone group and 31 of 57 patients (54.4%) in the placebo group developed hospital-acquired pneumonia by day 28 (HR, 0.47; 95% CI, 0.25-0.86; P = .01). Mechanical ventilation-free days increased with hydrocortisone by 4 days (95% CI, 2-7; P = .001) in the ITT analysis and 6 days (95% CI, 2-11; P < .001) in the modified ITT analysis. Hyponatremia was observed in 7 of 76 (9.2%) in the placebo group vs none in the hydrocortisone group (absolute difference, -9%; 95% CI, -16% to -3%; P = .01). Four of 76 patients (5.3%) in the placebo group and 6 of 73 (8.2%) in the hydrocortisone group died (absolute difference, 3%; 95% CI, -5% to 11%; P = .44). CONCLUSION: In intubated trauma patients, the use of an intravenous stress-dose of hydrocortisone, compared with placebo, resulted in a decreased risk of hospital-acquired pneumonia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00563303.

Domaines: Hépatologie et Gastroentérologie

Antoine Roquilly, Pierre Joachim Mahe, Philippe Seguin, Christophe Guitton, Hervé Floch, et al.. Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study.. Journal of the American Medical Association, 2011, 305 (12), pp.1201-9. ⟨10.1001/jama.2011.360⟩. ⟨hal-00741222⟩