Corticosteroid Replacement in Critical Illness

Intensivists routinely administer glucocorticoids, which are potent anti-inflammatory, immune, metabolic, and adrenergic modulating compounds at physiologic and pharmacologic doses. Recent investigations report increasing recognition of relative or absolute adrenal insufficiency in critically ill patients and the impact of cortisol responsiveness as a predictor of outcome for the critically ill. Several meta-analyses of studies from the 1970s and 1980s identified the lack of efficacy of “industrial” bolus doses of glucocorticoids (30 mg/kg of methylprednisolone or 6 mg/kg of dexamethasone) for short periods to treat septic shock patients within hours of diagnosis. Similarly, a large dose pulse therapy trial during the early evolution (exudative phase) of acute respiratory distress syndrome (ARDS) showed no benefit. Physiologic supplementation with glucocorticoids for refractory septic shock appears to be increasingly accepted, whereas pharmacologic steroid therapy during the fibroproliferative phase of ARDS remains under active evaluation. Therefore, this review discusses current rationales and evidence-based recommendations for acute glucocorticoid therapy in the critically ill, with specific focus on the need for steroid replacement therapy during critical illness or procedural stress.