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Corticosteroids in Critically Ill Patients: A Long and Winding Road

Corticosteroids in Critically Ill Patients: A Long and Winding Road In a recent issue, Dr Britt et al1 reported an increased morbidity in critically ill patients receiving steroids. The immunosuppressive properties of corticosteroids as well as other hazardous adverse effects such as hyperglycemia and myopathy are well-described and definite causes of morbidity in the critically ill. However, although the morbidity burden associated with corticosteroids cannot be underestimated, we believe the study's results should be viewed with caution because it presents significant shortcomings. A major drawback is imposed by dissimilar indications and, consequently, dosages, type, and duration of steroid treatment for a heterogeneous population. In the past decade, several studies revealed that severe infections and the immune response to microorganisms are implicated in hypothalamic-pituitary-adrenal axis alterations, resulting in a status of relative adrenocortical insufficiency.2,3 Recent studies provide strong evidence that patients with severe sepsis4 or severe community-acquired pneumonia5 have high rates of relative adrenal failure and can have significant improvement in organ function and mortality when treated with a short course (7-10 days) of low-dose hydrocortisone.4,6 Therefore, we believe the study by Britt et al1 should deliver a clear message: that corticosteroids should only be prescribed for critically ill patients with a precise indication and with attention to minimum effective dosages and that special awareness to infection prevention and glucose control should instituted. Conversely, despite the knowledge of its potentially harmful effects, corticosteroids should be given to patients with severe sepsis and adrenal insufficiency because they might play a key role in decreasing mortality in a critical scenario. Correspondence: Dr Salluh, Intensive Care Unit, Hospital Barra D’or, Rua Sambaiba 176/903, Rio de Janeiro, 22450-140, Brazil (jorgesalluh@yahoo.com.br). References 1. Britt RCDevine ASwallen KC et al. Corticosteroid use in the intensive care unit: at what cost? Arch Surg 2006;141145- 149PubMedGoogle ScholarCrossref 2. Beishuizen AThijs LG The immunoneuroendocrine axis in critical illness: beneficial adaptation or neuroendocrine exhaustion? Curr Opin Crit Care 2004;10461- 467PubMedGoogle ScholarCrossref 3. Annane DBellissant EBollaert PEBriegel JKeh DKupfer Y Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis. BMJ 2004;329480PubMedGoogle ScholarCrossref 4. Annane DSebille VCharpentier C et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288862- 871PubMedGoogle ScholarCrossref 5. Salluh JIVerdeal JCMello GW et al. Cortisol levels in patients with severe community-acquired pneumonia. Intensive Care Med 2006;32595- 598PubMedGoogle ScholarCrossref 6. Confalonieri MUrbino RPotena A et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 2005;171242- 248PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Corticosteroids in Critically Ill Patients: A Long and Winding Road

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Corticosteroids in Critically Ill Patients: A Long and Winding Road

Abstract

In a recent issue, Dr Britt et al1 reported an increased morbidity in critically ill patients receiving steroids. The immunosuppressive properties of corticosteroids as well as other hazardous adverse effects such as hyperglycemia and myopathy are well-described and definite causes of morbidity in the critically ill. However, although the morbidity burden associated with corticosteroids cannot be underestimated, we believe the study's results should be viewed with caution because it...
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References (6)

Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.141.9.945-a
Publisher site
See Article on Publisher Site

Abstract

In a recent issue, Dr Britt et al1 reported an increased morbidity in critically ill patients receiving steroids. The immunosuppressive properties of corticosteroids as well as other hazardous adverse effects such as hyperglycemia and myopathy are well-described and definite causes of morbidity in the critically ill. However, although the morbidity burden associated with corticosteroids cannot be underestimated, we believe the study's results should be viewed with caution because it presents significant shortcomings. A major drawback is imposed by dissimilar indications and, consequently, dosages, type, and duration of steroid treatment for a heterogeneous population. In the past decade, several studies revealed that severe infections and the immune response to microorganisms are implicated in hypothalamic-pituitary-adrenal axis alterations, resulting in a status of relative adrenocortical insufficiency.2,3 Recent studies provide strong evidence that patients with severe sepsis4 or severe community-acquired pneumonia5 have high rates of relative adrenal failure and can have significant improvement in organ function and mortality when treated with a short course (7-10 days) of low-dose hydrocortisone.4,6 Therefore, we believe the study by Britt et al1 should deliver a clear message: that corticosteroids should only be prescribed for critically ill patients with a precise indication and with attention to minimum effective dosages and that special awareness to infection prevention and glucose control should instituted. Conversely, despite the knowledge of its potentially harmful effects, corticosteroids should be given to patients with severe sepsis and adrenal insufficiency because they might play a key role in decreasing mortality in a critical scenario. Correspondence: Dr Salluh, Intensive Care Unit, Hospital Barra D’or, Rua Sambaiba 176/903, Rio de Janeiro, 22450-140, Brazil (jorgesalluh@yahoo.com.br). References 1. Britt RCDevine ASwallen KC et al. Corticosteroid use in the intensive care unit: at what cost? Arch Surg 2006;141145- 149PubMedGoogle ScholarCrossref 2. Beishuizen AThijs LG The immunoneuroendocrine axis in critical illness: beneficial adaptation or neuroendocrine exhaustion? Curr Opin Crit Care 2004;10461- 467PubMedGoogle ScholarCrossref 3. Annane DBellissant EBollaert PEBriegel JKeh DKupfer Y Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis. BMJ 2004;329480PubMedGoogle ScholarCrossref 4. Annane DSebille VCharpentier C et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288862- 871PubMedGoogle ScholarCrossref 5. Salluh JIVerdeal JCMello GW et al. Cortisol levels in patients with severe community-acquired pneumonia. Intensive Care Med 2006;32595- 598PubMedGoogle ScholarCrossref 6. Confalonieri MUrbino RPotena A et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 2005;171242- 248PubMedGoogle ScholarCrossref

Journal

Archives of Surgery – American Medical Association

Published: Sep 1, 2006

Keywords: adrenal corticosteroids,glucocorticoids,critical illness,mineralocorticoids

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