The use of corticosteroids in the treatment of critically ill patients has been the subject of controversy for decades. Information from recent clinical trials has helped to more clearly define their use in the acute setting. Cortisol is produced in response to pituitary corticortopin secretion which is in turn released in response to hypothalamic corticorpinreleasing hormone. Acute illness should result in increased cortisol production, although relative corticosteroid insufficiency can occur in sepsis and appears to be associated with increased mortality. Despite this, diagnosing corticosteroid insufficiency in patients with septic shock remains difficult. Investigators have failed to find a reliable relationship between random cortisol levels and mortality. However, recent evidence demonstrated an increase of serum cortisol < 9 mcg/dL following corticotropin stimulation is associated with increased mortality from septic shock. Corticosteroid replacement therapy in these patients reduces mortality. The mortality benefit seen in this setting may be limited to septic patients with acute respiratory distress syndrome. Corticosteroids have been used in a variety of conditions causing hypoxemic respiratory failure. While empiric steroids were widely used to treat ARDS in the 1970s and 1980s, more recent evidence from the ARDS clinical trial network failed to demonstrate a mortality benefit, despite the fact that patients were able to be weaned to unassisted breathing more quickly. Tight glycemic control in ARDS patients receiving corticosteroids can help avoid neuromyopathy and may afford an opportunity to prevent a return to assisted breathing in these patients. While steroids have also been reported for use in the treatment of SARS, no trials have been performed which support their efficacy.
Keywords: Corticotropin, sepsis, corticosteroids, ARDS, cortisol regulation, critical illness
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