Adult Critical Illness: Consider Corticosteroids
Adults with septic shock, ARDS or severe CAP. Not for children. Known adrenal insufficiency or long-term steroids with shock: treat as adrenal crisis.
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Corticosteroids in Septic Shock, ARDS and Severe CAP
Corticosteroids in Septic Shock, ARDS and Severe CAP: Adult Critical Illness: Consider Corticosteroids → Strongyloides Risk: Check Before Steroids → Whi...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning Strongyloides Risk: Check Before Steroids
Steroids can cause fatal Strongyloides hyperinfection
- At risk: lived in or travelled to endemic areas, in Australia (e.g. remote northern Australia) or overseas
- Send Strongyloides serology. Ask ID about empirical ivermectin
- Do not delay urgent steroids while waiting for the serology result
03Decision Which Indication Applies?
More than one can apply. Give one corticosteroid course only. Do not combine regimens.
- Septic shock
04Action Septic Shock: Suggest Corticosteroids
Vasopressor need persists despite fluids (SCCM 2024 and SSC 2026: conditional, low certainty)
- SCCM 2024: any vasopressor dose
- SSC 2021 threshold: noradrenaline or adrenaline 0.25 mcg/kg/min or more for at least 4 h
05Action Septic Shock: Hydrocortisone 200 mg/day IV
Adult: 50 mg IV every 6 h, or 200 mg/day by continuous infusion. One course only: do not add an ARDS or CAP regimen
- Known adrenal insufficiency or long-term steroids: hydrocortisone 100 mg IV stat, then 200 mg/24 h (adrenal crisis)
- With or without fludrocortisone 50 microgram enteral once daily (half a 100 microgram tablet)
- Duration: 7 days or until ICU discharge. Taper is optional
06Warning Septic Shock: Avoid High-Dose Short Courses
SCCM 2024: strong recommendation against
- Do not give more than 400 mg/day hydrocortisone-equivalent for less than 3 days
- No proven benefit and a risk of adverse effects
07Action Monitor While on Steroids
Watch for adverse effects
- Blood glucose: hyperglycaemia is common
- New or secondary infection
- Sodium: hypernatraemia
- Muscle weakness. GI bleeding: stress ulcer prophylaxis if risk factors
08Action Stop or Taper at End of Course
As set by the regimen used
- Septic shock: stop at day 7 or ICU discharge; taper optional
- CAP and ARDS: follow the trial taper
- Watch for recurrent hypotension after stopping
09Outcome Course Complete
Continue treatment of the cause and supportive care
- ARDS
10Action ARDS: Suggest Corticosteroids
Hospitalised adults with ARDS (SCCM 2024 and ATS 2024: conditional, moderate certainty)
- Evidence is mainly from intubated patients
- No preferred drug, dose or duration
11Warning ARDS: Check COVID-19, Influenza and Timing
Immunocompromise, metabolic syndrome, TB or parasite risk: monitor closely
- COVID-19: do not use the dexamethasone 20 mg regimen (higher mortality). Use COVID-19 guidance: dexamethasone 6 mg daily up to 10 days
- Influenza: no routine steroids unless another indication, such as septic shock. PJP with HIV: use the PJP regimen
- Do not start more than 14 days after ARDS onset: possible harm
12Action ARDS: Use One Trial Regimen
Adult doses. One course only; not with the septic shock regimen. Choose by timing and side-effect risk
- Early moderate to severe ARDS (within 24 h): dexamethasone 20 mg IV daily for 5 days, then 10 mg IV daily for 5 days or until extubation
- Early ARDS (within 72 h): methylprednisolone infusion for 14 days, then taper to day 28. Dose: see SCCM 2024 Table 4
- Unresolving ARDS (start day 7 to 14): methylprednisolone course to day 32. Dose: see SCCM 2024 Table 4
- Stop or shorten the course at extubation as the regimen states
- Path rejoins step 07Shared downstream outcome
- Severe CAP
13Action Severe Bacterial CAP: Recommend Corticosteroids
SCCM 2024: strong, moderate certainty. ATS 2025: conditional
- Severe: 1 major or 3 or more minor ATS/IDSA criteria
- Major: septic shock on vasopressors, or invasive ventilation
- Clinical suspicion of bacterial CAP on antibiotics is enough; no culture needed
- Less severe CAP: no SCCM recommendation; ATS 2025 recommends against
14Warning Severe CAP: Steroid Evidence Does Not Apply If...
Excluded from the trials or not covered by the recommendation
- Influenza (no routine steroids), Aspergillus or aspiration pneumonia
- Uncontrolled diabetes, recent GI bleeding, active TB or fungal infection, myelosuppression, long-term prednisone more than 15 mg/day
- Septic shock on vasopressors: use the septic shock regimen. COVID-19: follow COVID-19 guidance
15Action Severe CAP: Hydrocortisone Regimen
Adult. One course only. Start within 24 h of meeting severe criteria (CAPE COD)
- Hydrocortisone 200 mg/day by IV infusion for 4 days (8 days if not improving), then taper; total 8 or 14 days
- Stop hydrocortisone at ICU discharge
- Alternative: methylprednisolone 40 mg/day IV for 7 days, then taper to day 20
- Path rejoins step 07Shared downstream outcome
Guideline Source
2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, ARDS, and Community-Acquired Pneumonia
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Not for COVID-19: high-dose dexamethasone raised mortality in COVID-19.
- Best drug, dose and duration are uncertain. Doses are the regimens used in trials.
- Does not cover adrenal insufficiency testing or stress dosing in chronic steroid use.
- Does not cover Pneumocystis pneumonia, meningitis, asthma or COPD. SCCM 2024 makes no recommendation for children.
- Septic shock dosing follows SCCM 2024 and SSC 2021 trial regimens; SSC 2026 gives no fixed dose here.
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
AU: Strongyloides is endemic in parts of northern Australia, including remote communities. Screen at-risk patients before steroids.
Global: SCCM 2024 focused update; SSC 2026 (septic shock); ATS 2024 (ARDS); ATS 2025 (CAP)
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Corticosteroids in Septic Shock, ARDS and Severe CAP?
The Corticosteroids in Septic Shock, ARDS and Severe CAP is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, ARDS, and Community-Acquired Pneumonia.
What guideline is the Corticosteroids in Septic Shock, ARDS and Severe CAP based on?
This algorithm is based on 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, ARDS, and Community-Acquired Pneumonia (DOI: 10.1097/CCM.0000000000006172).
What are the limitations of the Corticosteroids in Septic Shock, ARDS and Severe CAP?
Known limitations include: Adults only. Not for COVID-19: high-dose dexamethasone raised mortality in COVID-19.; Best drug, dose and duration are uncertain. Doses are the regimens used in trials.; Does not cover adrenal insufficiency testing or stress dosing in chronic steroid use.; Does not cover Pneumocystis pneumonia, meningitis, asthma or COPD. SCCM 2024 makes no recommendation for children.; Septic shock dosing follows SCCM 2024 and SSC 2021 trial regimens; SSC 2026 gives no fixed dose here.. Individual patient factors may require deviation from these recommendations.
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