Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK)
The Society of Critical Care Medicine released updated guidelines on the use of corticosteroids in patients with sepsis, acute respiratory distress syndrome (ARDS), and community-acquired pneumonia (CAP). This post will provide the major takeaways for emergency clinicians.
Background
Many conditions we care for involve a dysregulated immune response, and corticosteroids may be beneficial in these settings, particularly in patients with critical-illness-related corticosteroid insufficiency (CIRCI). This is a state of systemic inflammation with a deregulated hypothalamus–pituitary–adrenal axis, altered cortisol metabolism, and tissue glucocorticoid resistance. Several recent studies have evaluated the use of corticosteroids in sepsis, ARDS, and severe CAP, conditions in which CIRCI is common.
A SCCM panel performed a systematic review and meta-analysis evaluating corticosteroids in adult patients with sepsis, ARDS, and CAP. Based on this meta-analysis, they provide several updated recommendations.
Recommendation Grading and Strength
Corticosteroids in Sepsis and Septic Shock
Recommendation 1A: They “suggest” administering corticosteroids to adult patients with septic shock (conditional recommendation, low certainty).
Recommendation 1B: They “recommend against” administration of high dose/short duration corticosteroids (> 400 mg/day hydrocortisone equivalent for < 3 days) for adult patients with septic shock (strong recommendation, moderate certainty).
They make no recommendation for corticosteroids in pediatric patients with sepsis or septic shock.
Considerations:
Authors found a total of 46 RCTs comparing corticosteroids with placebo or standard care in adult patients with sepsis or septic shock. They found corticosteroids may reduce hospital/long-term mortality (relative risk [RR] 0.94; 95% CI, 0.89–1.00, low certainty) and probably reduce ICU/short-term mortality (14–30 days) (RR 0.93; 95% CI, 0.88–0.98, moderate certainty). They also found corticosteroids improved shock reversal and (RR 1.24; 95% CI, 1.11–1.38, high certainty) and reduced organ dysfunction (MD 1.41 points lower Sequential Organ Failure Assessment score; 95% CI, 0.96 points lower to 1.87 points lower, high certainty) at 7 days, as well as reduced ICU and hospital length of stay. Corticosteroids increased neuromuscular weakness, hypernatremia, and hyperglycemia. There was uncertain effect on GI bleeding, super infection, stroke, and myocardial infarction.
Of note, the 2017 SCCM/ESICM guideline recommends corticosteroids in septic shock not responsive to fluids and moderate to high dose vasopressors. This current panel states steroids may be beneficial in patients with septic shock requiring vasopressors, no matter the dosage. The most common doses are hydrocortisone 200-300 mg/day, in divided doses or as a continuous infusion for 5-7 days.
In the ED, consider administering hydrocortisone 100 mg IV to patients with septic shock. Some studies include fludrocortisone 50 micrograms enterally daily in addition to hydrocortisone, with a potential mortality benefit. However, the panel made no recommendation on fludrocortisone.
Corticosteroids in ARDS
Recommendation 2A: They “suggest” administering corticosteroids to adult critically ill patients with ARDS (conditional recommendation, moderate certainty).
They make no recommendation for corticosteroids in pediatric patients with ARDS.
Considerations:
Authors found a total of 18 RCTs comparing corticosteroids with placebo or standard care in adult hospitalized patients with ARDS. Corticosteroids probably reduce 28-day mortality (RR 0.82; 95% CI, 0.72–0.95, moderate certainty) in critically ill patients with ARDS. A longer course (> 7 days) of corticosteroids was associated with higher rates of survival. Corticosteroids may lead to fewer ventilator days (low certainty) and shorter hospital length of stay (low certainty). There was in increase in hyperglycemia but uncertain effect on neuromuscular weakness and GI bleeding with corticosteroids.
The 2017 SCCM/ESICM guideline previously recommended giving methylprednisolone 1 mg/kg/day within 14 days of the diagnosis of moderate to severe ARDS (Pao2/Fio2 ratio of < 200). This panel, which included studies of COVID-19 and ARDS, removed the Pao2/Fio2 ratio. In the included RCTs, dosing regimens ranged from 40 mg/day to 2 mg/kg/day IV methylprednisolone equivalent with a common duration ranging from 7-30 days. Methylprednisolone, dexamethasone, and hydrocortisone with or without fludrocortisone were the most common steroids.
Corticosteroids in CAP
Recommendation 3A: They “recommend” administering corticosteroids to adult patients hospitalized with severe bacterial CAP (strong recommendation, moderate certainty).
Recommendation 3B: They “make no recommendation” for administering corticosteroids for adult patients hospitalized with less severe bacterial CAP.
They make no recommendation for corticosteroids in pediatric patients with CAP.
Considerations:
Authors found a total of 18 RCTs comparing corticosteroids with placebo or standard care in adult hospitalized patients with suspected or probably bacterial CAP (both severe and less severe). Severe pneumonia was defined as Pneumonia Severity Index of IV or V; Confusion, urea nitrogen, respiratory rate-65 scores of ≥ 3; confusion, oxygenation, respiratory and blood pressure scores of ≥ 22; systolic blood pressure, multilobar chest radiography, albumin, respiratory rate, tachycardia, confusion, oxygenation, arterial pH scores of ≥ 4; if patients were admitted to the ICU; or if they required IV vasopressor therapy. Ten trials included severe disease patients, and 8 trials less severe disease. In severe CAP, corticosteroids probably reduce hospital mortality (RR 0.62; 95% CI, 0.45–0.85; moderate certainty), but not less severe CAP (RR 1.08; 95% CI, 0.83–1.42; low certainty). In hospitalized patients with severe and less severe CAP, corticosteroids probably reduce need for invasive mechanical ventilation (moderate certainty) and may decrease duration of ICU (low certainty) and hospital stay (low certainty). Corticosteroids probably increase the risk of hyperglycemia (moderate certainty), may increase secondary infections (low certainty), but have uncertain effects on GI bleeding (low certainty).
The 2017 SCCM/ESICM guideline recommended corticosteroids for 5–7 days at a daily dose < 400 mg IV hydrocortisone or equivalent. This updated guideline recognizes that there are a variety of dosing strategies for severe CAP, with typical doses ranging from 40-80 mg/day IV methylprednisolone equivalent. If the patient has severe pneumonia, they are hypoxic, or will be admitted to the ICU, consider administering hydrocortisone 100-200 mg IV or methylprednisolone 40-80 mg IV.
Guideline Summary
Corticosteroid Administration Summary
Further Reading:
- 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 May 1;52(5):e219-e233.
- emDOCs Steroids Overview
- emDOCs EBM Update
- emDOCs Corticosteroids for Pneumonia
- emDOCs Corticosteroids for Sepsis
