Key Point

Although currently accepted for the treatment of the critically ill, corticosteroid use continues to pose serious risks to these patients—such as a greater chance of infection, and possibly, increased mortality.

NORFOLK, VA—Corticosteroid treatment of critically ill patients has fallen in and out of favor over the years since its introduction in the 1950s. Currently it is in favor, particularly for sepsis and relative adrenal insufficiency.

However, a recent study has once again confirmed the risks of these agents, associating the use of corticosteroids in the critically ill with increased rates of infection, more time on a mechanical ventilator, and lengthier ICU stays, as well as a tendency toward higher mortality.¹ "Caution must be taken to carefully consider the indications, risks, and benefits of corticosteroids when deciding on their use," stressed the study authors. Principal author Rebecca C. Britt, MD, is an Assistant Professor in the Department of Surgery at the Eastern Virginia Medical School in Norfolk.

The authors retrospectively studied the outcomes of 100 patients who were treated with corticosteroids in a burn/trauma ICU during a two-year period. These patients were compared to 100 controls treated at the same ICU who did not receive corticosteroids. The two groups were matched for age and Injury Severity Score and had similar medical histories, APACHE II scores, and Glasgow Coma Scale scores.

On average, the study group began corticosteroid treatment on ICU day 5, and the average length of treatment was 6.6 days. The most common reasons for prescribing corticosteroids were spinal cord injury, adrenal insufficiency, stridor/airway edema, and optic neuritis.

Interestingly, the authors maintained that corticosteroid therapy was supported by the literature in only 39 cases. "The remaining 61 should not have received corticosteroids based on a strict interpretation of the current literature," they argued.

Compared to controls, the corticosteroid group had a significantly greater incidence of pneumonia (26% vs 12%), bloodstream infection (19% vs 7%), and urinary tract infection (17% vs 8%), univariate analysis found. Corticosteroid use was associated with odds ratios of 2.64 for pneumonia and 3.25 for bloodstream infection in a multivariate model; the respective odds ratios for urinary tract infection, other infection, and mortality were 2.32, 2.58, and 1.89, but these findings were not quite significant.

After adjustment for confounders, the length of ICU stay was a mean of 7.35 days longer in the corticosteroid group than in the control group. The corticosteroid-treated patients required an average of approximately five more days of mechanical ventilation.

—Timothy Begany

Reference
1. Britt RC, Devine A, Swallen KC, et al. Corticosteroid use in the intensive care unit: at what cost? Arch Surg. 2006;141:145-149.

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