There is a long-drawn-out history with the use of corticosteroids in septic shock. In the 1980s, methylprednisolone was used in industrial strengths as a short course treatment, with predictably poor results.After several studies that suggested poor outcomes in septic shock, the use of corticosteroids slowly faded away. However, in the 1990s, there was a rekindling of interest with the use of corticosteroids in lower, more physiological doses, as replacement therapy, considering the possibility of “relative adrenal insufficiency” in septic shock. Three adequately powered randomized controlled trials have been published with the use of “physiological” dose corticosteroids in septic shock (Annane et al., Corticus, and ADRENAL). A pooled analysis of these three studies does not demonstrate improved survival with the use of corticosteroids in septic shock.
Fig 1. A pooled analysis of studies on mortality with the use of corticosteroids in septic shock
However, earlier shock reversal seems likely with the use of corticosteroids, as evidenced in most of the studies. The ADRENAL trial also revealed marginally lower ventilation days with corticosteroid use (6 vs. 7 days) with the initial episode of mechanical ventilation; however, there was no difference between groups with days alive and free of ventilation.
Severe acute respiratory distress syndrome (ARDS) may follow several acute illnesses, including sepsis, trauma, and acute pancreatitis. Corticosteroids are often used in patients who continue to remain hypoxic after optimization of mechanical ventilation. Meduri et al. carried out two RCTs,,with 1:2 randomization. Both studies seemed to favor the use of corticosteroids, with improved lung injury scores, improved oxygenation, and less time on ventilation. However, the results of the ARDSnet study of 180 patients with ARDS was different. Although steroid use was associated with improved P/F ratios and other parameters of respiratory physiology, there was no difference in the 60 or 180-day mortality. A pooled analysis of these three trials and a recent RCT does not show any survival advantage with the use of corticosteroids in ARDS
Fig 2. A pooled analysis of studies on mortality with the use of corticosteroids in ARDS
Are corticosteroids beneficial in community-acquired pneumonia (CAP)? One of the early studies on critically ill patients revealed improved P/F ratios, earlier resolution of shock, shorter hospital stay, and improved mortality.Subsequently, there have been several small RCTs that evaluated the possible beneficial effect of corticosteroids in CAP,,,,,. Most of these studies have been performed on patients with a low severity of illness, and low mortality. A pooled analysis of all studies carried out after 2005 suggests a mortality benefit with the use of corticosteroids (Fig 3).
Fig 3. A pooled analysis of studies on mortality with the use of corticosteroids in community-acquired pneumonia
However, several questions remain unanswered. Viral pneumonias are notorious to lead to a severe disease with profound impairment of oxygenation on occasions. We are seeing a resurgence of severe H1N1 pneumonia after several years in India. Would corticosteroids be of benefit in these patients? There are no robust data available to guide us in this situation. The limited evidence available so far seems to suggest that corticosteroids may have either have no effect or even be harmful in viral pneumonias.
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