Corticosteroid Use in Critical Care

Introduction to Corticosteroid Therapy

The American College of Physicians recommends administering corticosteroids (hydrocortisone 200-300 mg/day) to patients with septic shock who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy 1, 2
For severe community-acquired pneumonia with septic shock and/or requiring invasive mechanical ventilation, the Infectious Diseases Society of America recommends using adjunctive corticosteroids, particularly when CRP >150 mg/L 3, 10

The British Medical Journal guideline panel suggests that corticosteroids provide a weak but meaningful mortality benefit in septic shock, reducing 28-day mortality by approximately 2% (RR 0.84, 95% CI 0.73-0.96) 1, 2
Patients with refractory septic shock derive the greatest absolute mortality benefit from corticosteroids 3
The American College of Critical Care Medicine recommends hydrocortisone as the preferred agent for septic shock, based on the most extensive trial evidence 1, 6, 5

The Infectious Diseases Society of America recommends against routine corticosteroid use in general CAP patients, but suggests their use in severe CAP patients meeting specific criteria 3, 10
Severe CAP patients who receive adjunctive corticosteroids have reduced mortality (OR 0.26-0.39 in meta-analyses), decreased ARDS development, and reduced need for invasive mechanical ventilation 3, 10

The American Thoracic Society suggests using corticosteroids for patients with ARDS (conditional recommendation, moderate certainty evidence) 9
Corticosteroids in ARDS probably decrease mortality (17 studies, n=2,790; RR 0.84, 95% CI 0.73-0.96; moderate certainty) 9

The American College of Physicians recommends exercising extreme caution with viral CAP, particularly influenza, as meta-analyses show increased mortality with corticosteroid use in influenza patients 3
Patients who prioritize functional status and quality of life over mortality reduction may reasonably choose to forgo corticosteroids, given the potential for neuromuscular weakness that compromises independent function 2, 4