Corticosteroids in Septic Shock and ARDS

Algorithm Steps

1. ▶

   Start

   Critical Illness - Consider Corticosteroids

   Septic shock, ARDS, or severe CAP

   1. ◆

      Decision

      Identify Indication

      Which condition is being treated?

      1. ●

         Action

         Septic Shock

         Requiring vasopressors

         • SCCM 2024: Suggest corticosteroids
         • (Conditional recommendation, low certainty)
         1. ●

            Action

            Septic Shock: Hydrocortisone

            For vasopressor-dependent shock

            • Hydrocortisone 200-300 mg/day
            • Options: 50mg IV q6h OR continuous infusion
            • Duration: 5-7 days, then taper
            • Start when NE ≥0.25 mcg/kg/min
            • ⚠️ AVOID high dose short duration (>400mg/day <3 days)
            1. ⚠

               Warning

               ⚠️ Avoid High-Dose/Short Duration

               Strong recommendation AGAINST

               • Do NOT give >400mg hydrocortisone equiv/day
               • Do NOT give for <3 days
               • Associated with worse outcomes
               • Rebound hypotension risk
            2. ●

               Action

               Monitoring on Steroids

               Watch for adverse effects

               • Blood glucose (insulin often needed)
               • Secondary infections
               • Hypernatremia
               • GI bleeding prophylaxis
               • Neuromuscular weakness with prolonged use
               1. ●

                  Action

                  Taper and Discontinue

                  Avoid abrupt discontinuation

                  • Taper over 2-4 days
                  • Or stop after 5-7 days if short course
                  • Monitor for rebound hypotension
                  • No cosyntropin stimulation test needed routinely
                  1. ✓

                     Outcome

                     Shock Resolving / ARDS Improving

                     Wean vasopressors, continue care

                  2. ✓

                     Outcome

                     No Clear Benefit

                     Continue supportive care, steroids may still be continued

      2. ●

         Action

         ARDS

         Hospitalized with ARDS

         • SCCM 2024: Suggest corticosteroids
         • (Conditional recommendation, moderate certainty)
         1. ●

            Action

            ARDS: Corticosteroids

            Various regimens used

            • Dexamethasone 20mg daily x5d, then 10mg x5d
            • OR Methylprednisolone 1-2 mg/kg/day
            • Duration: 7-14 days, taper
            • No consensus on optimal regimen
            • Consider for moderate-severe ARDS
      3. ●

         Action

         Severe CAP

         Hospitalized with severe bacterial pneumonia

         • SCCM 2024: Recommend corticosteroids
         • (Strong recommendation, moderate certainty)
         1. ●

            Action

            Severe CAP: Corticosteroids

            Strong recommendation

            • Hydrocortisone 200mg/day
            • OR Methylprednisolone 40mg/day
            • OR Dexamethasone 6mg/day
            • Duration: 4-7 days
            • Start within 24h of admission