Guidelines for steroid use in ards

RLUH ICU: Guidelines for the Use of Steroids In ARDS in the ITU GUIDELINES FOR THE USE OF STEROIDS IN ARDS IN THE ITU Various regimens are described in the literature: 1. • Treatment commenced after 15 +/- 7.5 days • Methylprednisolone 200 mg bolus then: • 2–3 mgkg-1day-1 until extubated then taper over 6 weeks Refs: Meduri et al. Chest 1994; 105: 1516–1527 See also letter in Crit Care Med June 1995 p1157


2.
• Days 6–10 methylprednisolone 125 mg IV QDS
• Day 11: 60 mg IV QDS tapered over several weeks Crit Care Med June 1998 p1290 3. • From day 7 load 2 mg/kg methylprednisolone then: • 2 mgkg-1day-1 for 14 days then taper until day 32 Meduri et al. JAMA; 1998; 280: 159--165 New Horizons 1999; 7: 127 4. • Methylprednisolone from about day 10: • Taper immediately but over > 27 days Refs: Int Care Med May 2000; 526–531 _______________________________________________________________________________ Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646. RLUH ICU: Guidelines for the Use of Steroids In ARDS in the ITU Glucocorticoids and acute lung injury.
Critical Care Medicine. 31(4) Supplement:S253-S257, April 2003.
Thompson, B. Taylor MD
Abstract:
Objectives: To describe hypothalamic-pituitary-adrenal (HPA) activation
and the role of glucocorticoids in immune modulation during critical
illness, and to review clinical trials of pharmacologic and "replacement"'
doses of glucocorticoids in early and late acute respiratory distress
syndrome (ARDS) and sepsis.
Data Extraction and Synthesis: Selected review of published literature (1963 to present), clinical trials, and meta-analyses. Data Summary: HPA axis activation is an important component of the compensatory anti-inflammatory response to critical illness. Cortisol supports vascular tone and endothelial integrity, modulates a large number of proinflammatory cytokines, and suppresses phospholipase A2, cyclo-oxygenase, and nitric oxide synthase. Cortisol has putative antifibrotic activities, including inhibition of fibroblast growth and collagen deposition and stimulation of T-cell and monocyte apoptosis. During critical illness, neurohumoral factors, cytokines, endothelin, and atrial natriuretic peptide all may participate in HPA axis activation, resulting in elevated plasma cortisol production and plasma concentrations. In general, cortisol concentrations correlate with severity of illness, and higher plasma concentrations are associated with a poorer outcome. Failure of adrenocorticotropic hormone to augment plasma cortisol appears to be a poor prognostic finding in vasopressor-dependent sepsis and may indicate "relative adrenal insufficiency." Replacement glucocorticoid/mineralocorticoid therapy over 7 days appears to be beneficial in such individuals. However, a meta-analysis of high-dose, short-course glucocorticoid treatment involving 1,297 patients with sepsis enrolled in nine trials showed a trend toward harm, and four trials in patients with, or at risk for, ARDS showed no benefit or a greater likelihood of progression to ARDS. In contrast, observational studies and one small randomized controlled trial suggest that lower pharmacologic doses of glucocorticoids given late (>1 wk) in the course of ARDS may be beneficial. The National Heart, Lung, and Blood Institute's ARDS Network currently is testing the use of methylprednisolone in late ARDS. This study was reviewed by an independent data safety monitoring board for safety and efficacy after enrolling 60 and 120 patients and is currently ongoing. Conclusion: Current evidence indicates that short-duration, high-dose glucocorticoid therapy is not effective for early ARDS or severe sepsis. One small randomized, controlled trial suggests that moderate doses of glucocorticoids may be beneficial for patients with late ARDS; a much larger randomized controlled trial is ongoing. Some patients with _______________________________________________________________________________ Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646. RLUH ICU: Guidelines for the Use of Steroids In ARDS in the ITU pressor-dependent severe sepsis appear to have relative adrenal insufficiency and benefit from replacement glucocorticoid/mineralocorticoid therapy. The accuracy of the diagnostic criteria for, and the prevalence of, relative adrenal insufficiency in patients with acute lung injury/ARDS is unknown. It is also unclear whether such a response, if present, predisposes patients to ongoing lung inflammation and the development of late fibroproliferative ARDS, or if it is predictive of a beneficial response to steroids. Studies of HPA axis activation and the role of relative adrenal insufficiency on the outcome of patients with acute lung injury are needed. _______________________________________________________________________________ Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646.

Source: http://www.amicu.org/glines/Steroid%20use%20in%20ARDS%20(2003).pdf