Corticosteroid Use in Critical Illness

Indications and Regimens

The American College of Critical Care Medicine recommends corticosteroids for hospitalized patients with community-acquired pneumonia (CAP), particularly severe cases, with a regimen of corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent 1
Corticosteroids are recommended for post-cardiac arrest patients, with benefits including improved shock reversal, survival to hospital discharge, and good neurological recovery 1
The use of corticosteroids is also recommended for patients undergoing cardiopulmonary bypass surgery, with benefits including reduced risk of mortality and atrial fibrillation 1
For patients with septic shock that is not responsive to fluid resuscitation and moderate-to-high-dose vasopressor therapy, intravenous hydrocortisone at a dose of <400 mg/day should be administered for at least 3 days at full dose, as recommended by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine 2, 1
For early moderate to severe ARDS (PaO2/FiO2 < 200 and within 14 days of onset), the recommended regimen is IV methylprednisolone 1 mg/kg/day, according to the American Thoracic Society 2

The use of corticosteroids in specific critical illness scenarios, including septic shock and early moderate to severe ARDS, can provide benefits such as shortened hospital stay, reduced need for mechanical ventilation, and prevention of ARDS 1
However, evidence suggests that corticosteroids may increase mortality (OR 2.82; 95% CI, 1.61-4.92) and risk of superinfection in patients with influenza 1
Critical Illness-Related Corticosteroid Insufficiency (CIRCI) is a condition characterized by dysregulated systemic inflammation resulting from inadequate intracellular glucocorticoid-mediated anti-inflammatory activity, associated with increased morbidity, ICU length of stay, and mortality 2

CIRCI should be suspected in patients presenting with cardiovascular signs such as hypotension refractory to fluid resuscitation, decreased sensitivity to catecholamines, neurological signs such as confusion, delirium, coma, respiratory signs such as persistent hypoxia, and laboratory abnormalities such as hypoglycemia, hyponatremia, hyperkalemia, and metabolic acidosis 2
Diagnostic approaches for CIRCI include delta cortisol (change in baseline cortisol at 60 min of <9 μg/dL) after cosyntropin (250 μg) administration, random plasma cortisol of <10 μg/dL, and plasma total cortisol levels 2
Regular glucose monitoring is essential, as hyperglycemia is the most common adverse effect 2
Monitor for electrolyte disturbances such as hypernatremia and hypokalemia, and enhanced infection surveillance is recommended as glucocorticoid treatment can blunt febrile response 2, 3

Corticosteroids are not recommended for patients with major trauma, as stated by the Society of Critical Care Medicine 2
Corticosteroids are not recommended to use in adult patients with sepsis without shock, as recommended by the Surviving Sepsis Campaign 2
Short-term use (2-4 weeks): Generally safe with minimal risk of systemic effects, according to the American Academy of Dermatology 4
Prolonged use increases risk of local effects, such as skin atrophy, telangiectasia, striae, purpura, and systemic effects, such as HPA axis suppression, especially with medium to high potency formulations 4

Slow tapering over 6-14 days is recommended rather than abrupt discontinuation to prevent inflammatory rebound, although the exact duration is not specified in the provided references 2, 3
Consider reinitiating therapy for patients who deteriorate after stopping corticosteroids, as suggested by clinical judgment 2, 3
Typical duration in clinical trials for septic shock is 7-14 days total, or less for those rapidly improving, as suggested by the British Medical Journal 3
Gradual reduction is recommended following clinical response to prevent adrenal insufficiency, according to the American Academy of Dermatology 4
Watch for signs of adrenal insufficiency when tapering or discontinuing, according to the American Academy of Dermatology 5