AS A CRITICAL CARE PHARMACIST, you will hear more buzz about using corticosteroids to treat critical illness-related corticosteroid insufficiency (CIRCI). A number of critical illnesses can lead to CIRCI. Determine steroid treatment based on clinical indication since cortisol testing doesn't clearly pinpoint who might benefit.
SEPTIC SHOCK. Two trials are reigniting debate about steroid use with decreased mortality in one trial but not the other. Both trials suggest faster shock resolution and other benefits with steroids. But the trial with mortality benefit includes sicker patients with more blood, respiratory, and urinary infections. Continue to consider steroids in sepsis when blood pressure doesn't adequately respond to IV fluids and pressors especially when "norepinephrine-equivalent" rates are consistently 0.25 mcg/kg/min or higher.
Start hydrocortisone (Solu-Cortef) 200 mg/day as 50 mg IV Q6 hours or a continuous infusion. Consider continuing for at least 3 days and until pressors are stopped and tapering doses that continue past 7 days. Don't feel compelled to add fludrocortisone. Hydrocortisone (Solu-Cortef) alone is usually enough.
COMMUNITY-ACQUIRED PNEUMONIA (CAP). Consider a steroid for severe CAP to possibly prevent one death for every 18 patients treated. Lean toward a prednisone-equivalent dose of 40 to 50 mg/day for 5 to 10 days. For further information, see note on Consider using steroids for community acquired pneumonia (CAP) patients.
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS). Don't routinely reach for steroids to treat ARDS. It's still too soon to know who may benefit. But if steroids are used, stick to patients with a PaO2/FiO2 under 200. Start within 14 days, and include a slow taper over a week or two. Lean toward methylprednisolone (Solu-Medrol) 1 mg/kg/day due to its lung penetration.
REFERENCES
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Venkatesh B, Finfer S, Cohen J, Rajbhandari D, Arabi Y, Bellomo R, Billot L, Correa M, Glass P, Harward M, Joyce C, Li Q, McArthur C, Perner A, Rhodes A, Thompson K, Webb S, Myburgh J; ADRENAL Trial Investigators and the Australian–New Zealand Intensive Care Society Clinical Trials Group. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med. 2018 Mar 1;378(9):797-808. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1705835?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov
Annane D, Renault A, Brun-Buisson C, Megarbane B, Quenot JP, Siami S, Cariou A, Forceville X, Schwebel C, Martin C, Timsit JF, Misset B, Ali Benali M, Colin G, Souweine B, Asehnoune K, Mercier E, Chimot L, Charpentier C, François B, Boulain T, Petitpas F, Constantin JM, Dhonneur G, Baudin F, Combes A, Bohé J, Loriferne JF, Amathieu R, Cook F, Slama M, Leroy O, Capellier G, Dargent A, Hissem T, Maxime V, Bellissant E; CRICS-TRIGGERSEP Network. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med. 2018 Mar 1;378(9):809-818. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1705716?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov
Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A, Briegel J, Carcillo J, Christ-Crain M, Cooper MS, Marik PE, Umberto Meduri G, Olsen KM, Rodgers SC, Russell JA, Van den Berghe G. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med. 2017 Dec;45(12):2078-2088. Available at: https://journals.lww.com/ccmjournal/Fulltext/2017/12000/Guidelines_for_the_Diagnosis_and_Management_of.16.aspx
Pastores SM, Annane D, Rochwerg B; Corticosteroid Guideline Task Force of SCCM and ESICM. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med. 2018 Jan;46(1):146-148. Available at: https://journals.lww.com/ccmjournal/Fulltext/2018/01000/Guidelines_for_the_Diagnosis_and_Management_of.19.aspx