J Neurocrit Care.  2017 Dec;10(2):86-91. 10.18700/jnc.170030.

Corticosteroid Treatment in Critically Ill Patients

• Lee S
• Ryu JA

• KMID: 2405762
• DOI: http://doi.org/10.18700/jnc.170030

Abstract

Increased levels of tissue corticosteroids are associated with important protective responses of critically ill patients. Critical illness and its treatment interfere with the normal corticosteroid response to illness and induce tissue corticosteroid insufficiency. Therefore, corticosteroid is commonly used in critically ill patients. In intensive care units, the main reasons for using steroids are critical illness-related corticosteroid insufficiency (CIRCI), septic shock, acute respiratory distress syndrome (ARDS), airway edema, etc. CIRCI may be suspected due to symptoms or signs such as unconsciousness, hemodynamic instability, fever, or electrolyte imbalance. An adrenocorticotropic hormone stimulation test or measurement of a random plasma cortisol level is necessary to diagnose CIRCI. Corticosteroid administration can be helpful when CIRCI is confirmed. Similar to CIRCI, corticosteroid can be used in septic shock. However, corticosteroid administration is not recommended for patients with sepsis without shock. The use of corticosteroid in patients with ARDS is still controversial. Although steroids are commonly used for critically ill patients, there are controversies related to the use of steroids in the intensive care unit. In this article, we review the physiology of the corticosteroid response to critical illness and practical issues relating to the diagnosis and treatment of corticosteroid insufficiency in critically ill patients.

Keyword

Adrenal insufficiency; Septic shock; Acute respiratory distress syndrome; Intensive care unit

MeSH Terms

Adrenal Cortex Hormones
Adrenal Insufficiency
Adrenocorticotropic Hormone
Critical Illness*
Diagnosis
Edema
Fever
Hemodynamics
Humans
Hydrocortisone
Intensive Care Units
Physiology
Plasma
Respiratory Distress Syndrome, Adult
Sepsis
Shock
Shock, Septic
Steroids
Unconsciousness
Adrenal Cortex Hormones
Adrenocorticotropic Hormone
Hydrocortisone
Steroids

Reference

1. Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med. 2003; 348:727–34.

2. Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A, et al. 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. Intensive Care Med. 2017; 43:1751–63.

3. Britt RC, Devine A, Swallen KC, Weireter LJ, Collins JN, Cole FJ, et al. Corticosteroid use in the intensive care unit: at what cost? Arch Surg. 2006; 141:145–9. discussion 149.

4. Gibbison B, López-López JA, Higgins JP, Miller T, Angelini GD, Lightman SL, et al. Corticosteroids in septic shock: a systematic review and network meta-analysis. Crit Care. 2017; 21:78.

5. Trubelja AD. Current use of steroids in critical care. SOJ Anesthesiol Pain Manag. 2014; 1:1–4.

6. Steinberg KP, Hudson LD, Goodman RB, Hough CL, Lanken PN, Hyzy R, et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med. 2006; 354:1671–84.

7. Marik PE. Critical illness-related corticosteroid insufficiency. Chest. 2009; 135:181–93.

8. Perrot D, Bonneton A, Dechaud H, Motin J, Pugeat M. Hypercortisolism in septic shock is not suppressible by dexamethasone infusion. Crit Care Med. 1993; 21:396–401.

9. Chrousos GP. The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. N Engl J Med. 1995; 332:1351–62.

10. Wagner RL, White PF, Kan PB, Rosenthal MH, Feldman D. Inhibition of adrenal steroidogenesis by the anesthetic etomidate. N Engl J Med. 1984; 310:1415–21.

11. Catalano RD, Parameswaran V, Ramachandran J, Trunkey DD. Mechanisms of adrenocortical depression during Escherichia coli shock. Arch Surg. 1984; 119:145–50.

12. Burchard K. A review of the adrenal cortex and severe inflammation: quest of the “eucorticoid” state. J Trauma. 2001; 51:800–14.

13. Marik PE, Pastores SM, Annane D, Meduri GU, Sprung CL, Arlt W, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008; 36:1937–49.

14. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43:304–77.

15. Keh D, Boehnke T, Weber-Cartens S, Schulz C, Ahlers O, Bercker S, et al. Immunologic and hemodynamic effects of “low-dose” hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med. 2003; 167:512–20.

16. Huh JW, Choi HS, Lim CM, Koh Y, Oh YM, Shim TS, et al. Low-dose hydrocortisone treatment for patients with septic shock: a pilot study comparing 3days with 7days. Respirology. 2011; 16:1088–95.

17. Weber-Carstens S, Deja M, Bercker S, Dimroth A, Ahlers O, Kaisers U, et al. Impact of bolus application of low-dose hydrocortisone on glycemic control in septic shock patients. Intensive Care Med. 2007; 33:730–3.

18. Meduri GU, Headley AS, Golden E, Carson SJ, Umberger RA, Kelso T, et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1998; 280:159–65.

19. Adhikari N, Burns KE, Meade MO. Pharmacologic treatments for acute respiratory distress syndrome and acute lung injury: systematic review and meta-analysis. Treat Respir Med. 2004; 3:307–28.

20. Agarwal R, Nath A, Aggarwal AN, Gupta D. Do glucocorticoids decrease mortality in acute respiratory distress syndrome? A meta-analysis. Respirology. 2007; 12:585–90.

21. Peter JV, John P, Graham PL, Moran JL, George IA, Bersten A. Corticosteroids in the prevention and treatment of acute respiratory distress syndrome (ARDS) in adults: meta-analysis. BMJ. 2008; 336:1006–9.

22. Tang BM, Craig JC, Eslick GD, Seppelt I, McLean AS. Use of corticosteroids in acute lung injury and acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care Med. 2009; 37:1594–603.

23. Lamontagne F, Briel M, Guyatt GH, Cook DJ, Bhatnagar N, Meade M. Corticosteroid therapy for acute lung injury, acute respiratory distress syndrome, and severe pneumonia: a meta-analysis of randomized controlled trials. J Crit Care. 2010; 25:420–35.

24. Ruan SY, Lin HH, Huang CT, Kuo PH, Wu HD, Yu CJ. Exploring the heterogeneity of effects of corticosteroids on acute respiratory distress syndrome: a systematic review and metaanalysis. Crit Care. 2014; 18:R63.

25. Meduri GU, Marik PE, Chrousos GP, Pastores SM, Arlt W, Beishuizen A, et al. Steroid treatment in ARDS a critical appraisal of the ARDS network trial and the recent literature. Intensive Care Med. 2008; 34:61–9.

26. Confalonieri M, Urbino R, Potena A, Piattella M, Parigi P, Puccio G, et al. Hydrocortisone infusion for severe communityacquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med. 2005; 171:242–8.

27. Annane D, Sébille V, Bellissant E; Ger-Inf-05 Study Group. Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med. 2006; 34:22–30.

28. Weigelt JA, Norcross JF, Borman KR, Snyder WH 3rd. Early steroid therapy for respiratory failure. Arch Surg. 1985; 120:536–40.

29. Darmon JY, Rauss A, Dreyfuss D, Bleichner G, Elkharrat D, Schlemmer B, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. Anesthesiology. 1992; 77:245–51.

30. Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care. 2007; 11:R72.

31. Fan T, Wang G, Mao B, Xiong Z, Zhang Y, Liu X, et al. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials. BMJ. 2008; 337:a1841.

32. Cho YJ, Moon JY, Shin ES, Kim JH, Jung H, Park SY, et al. Clinical practice guideline of acute respiratory distress syndrome. Tuberc Respir Dis (Seoul ). 2016; 79:214–33.

33. Bone RC, Fisher CJ Jr, Clemmer TP, Slotman GJ, Metz CA. Early methylprednisolone treatment for septic syndrome and the adult respiratory distress syndrome. Chest. 1987; 92:1032–6.

34. Bernard GR, Luce JM, Sprung CL, Rinaldo JE, Tate RM, Sibbald WJ, et al. High-dose corticosteroids in patients with the adult respiratory distress syndrome. N Engl J Med. 1987; 317:1565–70.

35. Annane D, Sébille V, Bellissant E; Ger-Inf-05 Study Group. Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med. 2006; 34:22–30.

36. Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest. 2007; 131:954–63.