Many acutely ill patients have a dysregulated systemic inflammatory response, characterized by hypothalamic-pituitary-adrenal axis dysfunction, altered cortisol metabolism, and tissue corticosteroid resistance.
Corticosteroids are used in critical illness, particularly in conditions such as sepsis, community acquired pneumonia and acute respiratory distress syndrome (ARDS).
The Society of Critical Care Medicine (SCCM) recommends the use of corticosteroids in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy.
Corticosteroids can reduce organ dysfunction and increase shock reversal, although they may increase the risk of neuromuscular weakness, hypernatremia, and hyperglycemia.
For ARDS corticosteroids probably reduce 28-day mortality and may decrease the duration of mechanical ventilation and hospital length of stay.
However, the use of corticosteroids in ARDS is associated with an increased risk of hyperglycemia.
In terms of dosage, the most common regimen for septic shock involves intravenous hydrocortisone at 200-300 mg per day, administered in divided doses or as a continuous infusion for 5-7 days, with or without a taper.
Some studies also include fludrocortisone 50 µg enterally daily in addition to hydrocortisone.
Overall, the use of corticosteroids in critical illness is supported by evidence of benefits in reducing organ dysfunction and improving shock reversal in septic shock, as well as potential mortality benefits in ARDS, despite some risks of adverse effects.
The use of corticosteroids in critical illness extends to specific conditions such as severe pulmonary infections, including COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia: low-dose corticosteroids (≤400 mg hydrocortisone equivalent daily) can reduce mortality in these conditions.
Dexamethasone 6 mg daily for 10 days decreased 28-day mortality in patients with severe COVID-19 requiring supplemental oxygen or mechanical ventilation.
For acute respiratory distress syndrome (ARDS), guidelines suggest that corticosteroids probably decrease mortality and may reduce the duration of mechanical ventilation and hospital stay, although they are associated with an increased risk of hyperglycemia.
For septic shock, the use of hydrocortisone at 200 mg per day has shown conflicting results in terms of mortality benefits, but it is associated with earlier shock reversal.
Corticosteroids are beneficial in reducing mortality and improving outcomes in critically ill patients with severe pulmonary infections, ARDS, and septic shock, although their use must be balanced against potential adverse effects such as hyperglycemia, gastrointestinal bleeding, and secondary infections.