Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI): Updated Guidelines 2017

ARDS

In patients with early moderate-to-severe ARDS (PaO2/FIO2 of less than 200 and within 14 days of onset), the task force recommended the use of IV methylprednisolone in a dose of 1 mg/kg/day followed by slow tapering over 2 weeks to prevent the development of a rebound inflammatory response, and adherence to infection surveillance. In patients with major trauma and influenza, the panel suggested against the use of corticosteroids. Corticosteroids were recommended for patients with severe community-acquired pneumonia (less than 400 mg/day of IV hydrocortisone or equivalent for 5 to 7 days), meningitis, adults undergoing cardiopulmonary bypass surgery, and adults who suffer a cardiac arrest. The task force highlighted that the quality of evidence for the use of corticosteroids in these disease states was often low and that additional well-designed RCTs with carefully selected patients were warranted.

To conclude, as with any clinical practice guideline, the task force reiterated that the updated CIRCI guidelines were not intended to define a standard of care and should not be interpreted as prescribing an exclusive course of management. Good clinical judgment should always prevail!

Dr. Pastores is Program Director, Critical Care Medicine, Vice-Chair of Education, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center; Professor of Medicine and Anesthesiology, Weill Cornell Medical College, New York, NY.