Study indicates problems with using corticosteroids in the ICU.
Health care practitioners may currently favor the use of corticosteroids in the intensive care unit (ICU), especially in the setting of sepsis and relative adrenal insufficiency. A new study, however, associates corticosteroid use in the ICU with increased rate of infection, more time spent in the ICU and on ventilators, and possibly increased mortality.
The researchers who conducted the study, which was published in the February issue of the Archives of Surgery, say that the increasing use of corticosteroids by practitioners for treatment of sepsis has led to an increasing level of comfort with the use of corticosteroids for other indications in the critically ill. The study was designed to evaluate the morbidity and mortality related to corticosteroid use in the trauma ICU.
To conduct their study, the researchers queried a trauma database for the years 2002 to 2003 for all patients admitted to the trauma and burn ICU of a Level 1 trauma center. The computerized pharmacy orders were then queried for each patient for the use of methylprednisolone, hydrocortisone, dexamethasone, and prednisone. The process identified 100 patients who had received corticosteroids while in the trauma ICU.
The corticosteroid recipients were then matched by age and injury severity score to a control group of 100 patients treated in the ICU during the same period but without corticosteroids. The researchers used the Statistical Analysis System software to assess the links between corticosteroid use and each of seven outcomes (pneumonia, bloodstream infections, urinary tract infection, other infections, ICU length of stay (LOS), ventilator length of stay, and death) with univariate analysis. They also conducted multivariate regression analysis (logistic regression and ordinary least squares), controlling for age, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, and medical history.
The researchers found no significant difference between the two groups for Glasgow Coma Scale score, APACHE II score, and medical history. In univariate analysis, the corticosteroid group had a significant increase in pneumonia (26% vs. 12%), bloodstream infection (19% vs. 7%), and urinary tract infection (17% vs. 8%). In multivariate models, corticosteroid use was associated with an increased rate of pneumonia and bloodstream infection. There was a trend toward increased urinary tract infection, other infections, and mortality. Patients in the ICU who received corticosteroids had a longer ICU LOS by seven days and longer ventilator LOS by five days.
Overall, the researchers conclude, "caution must be taken to carefully consider the indications, risks, and benefits of corticosteroids when deciding on their use."
These researchers have clearly articulated the results of a well-designed case-control study, say Michael F. Rotondo, MD, FACS, and Paul J. Schenarts, MD. They published their comments in the journal in an "invited critique" of the study. Rotondo is professor of surgery, vice chairman for clinical affairs, and chief of trauma and surgery critical care at the Brody School of Medicine at East Carolina University in Greenville, NC. Schenarts is an assistant professor of trauma and surgical critical care at the school.
The researchers’ findings of significantly increased rates of pneumonia, bloodstream infections, urinary tract infections, ventilator days, and ICU length of stay serve as a warning to those who advocate increased steroid use, the reviewers say. "It is also noteworthy that these results may have been even more significant, had their institution not already implemented a series of protocols designed to limit infections."
"If one considers the indications for the use of steroids in the ICU, the benefits may not outweigh the risks," Rotondo and Schenarts say. Literature does not fully support the use of steroids to treat traumatic optic injury and also does not provide guidance for steroid use in "relative" adrenal insufficiency. In addition, steroids may not alter reintubation rates in those with airway edema, they say. Furthermore, steroid use in sepsis remains controversial, and steroids have not been used as much in the treatment of spinal cord injury.
"Given the paucity of documented benefit," they conclude, "the infectious risks of steroids need to be carefully considered before initiation of therapy."