UMEM Educational Pearls

Title: Steroids in the Critically Ill

Keywords: Corticosteroids, septic shock, ARDS, acute respiratory distress syndrome, community acquired pneumonia, CAP, dexamethasone, methylprednisolone, hydrocortisone (PubMed Search)

Posted: 7/9/2024 by Kami Windsor, MD
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This May, the Society of Critical Care Medicine (SCCM) published new recommendations [1] for the use of corticosteroids in critical illness (separate from patients with known adrenal insufficiency or on chronic steroids), namely:

“Suggesting” for all septic shock with continued vasopressor requirement not just “refractory” (requiring 2+ pressors)
- Matches the 2021 Surviving Sepsis Campaign Guidelines suggestion [2]
“Suggesting” for ARDS (acute onset, bilateral infiltrates not due to cardiac dysfunction or volume overload, PaO2: FiO2 </= 300)
- Matches the 2024 American Thoracic Society Clinical Practice Guidelines suggestion [3]
- Does not explicitly exclude influenza+ ARDS, in which steroids have previously been associated with worsened outcomes [4]
“Recommending” for patients with bacterial community acquired pneumonia and new O2 requirement
- New guidelines from ATS/IDSA not yet updated from 2019; support primarily from 2023 CAPE COD trial [5]

Bottom Line:

For severe bacterial pneumonia and septic shock, ED physicians should feel comfortable administering a dose of hydrocortisone 50mg IV as hydrocortisone 200mg/day is an accepted regimen for these disease processes.

For patients with ARDS who remain boarding in the ED, EM docs should discuss initiation of steroids with their intensivists, whether the institutional preference is for dexamethasone 20mg IV (per DEXA-ARDS) [6] or methylprednisolone 1mg/kg/day (per Meduri)[7].

References

Chaudhuri D, Nei AM, Rochwerg B, et al. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52(5):e219-e233. doi: 10.1097/CCM.0000000000006172.
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi: 10.1007/s00134-021-06506-y.
Qadir N, Sahetya S, Munshi L, et al. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024;209(1):24-36. doi: 10.1164/rccm.202311-2011ST.
Ni YN, Chen G, Sun J, et al. The effect of corticosteroids on mortality of patients with influenza pneumonia: a systematic review and meta-analysis. Crit Care_._ 2019;23(1):99. doi: 10.1186/s13054-019-2395-8.
Dequin PF, Meziani F, Quenot JP, et al; CRICS-TriGGERSep Network. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941. doi: 10.1056/NEJMoa2215145.
Villar J, Ferrando C, Martínez D, et al; dexamethasone in ARDS network. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Respir Med. 2020 Mar;8(3):267-276. doi: 10.1016/S2213-2600(19)30417-5.
Meduri GU, Golden E, Freire AX, et al. Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest. 2007;131(4):954-63. doi: 10.1378/chest.06-2100.