Steroid Use in the ICU 

Steroids are commonly used in the ICU for shock, ARDS, COPD/asthma, adrenal insufficiency, meningitis, and spinal cord injury (rarely now).

 

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1. Septic Shock (Refractory)

Indication:

• Shock requiring ≥0.1 mcg/kg/min norepinephrine

• Persistent shock > 4–6 hours despite fluids/pressors

Preferred steroid:

Hydrocortisone 200 mg/day

• 50 mg IV q6h or

• Continuous infusion 200 mg/day

Optional add-on:

Fludrocortisone 50 mcg PO daily

(Surviving Sepsis trials added this)

Goal:

• Faster shock reversal

• Little mortality benefit, but reduces time on pressors

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2. ARDS (Moderate–Severe)

Indication: PaO₂/FiO₂ < 200 or early severe ARDS

Steroid regimen:

Dexamethasone 20 mg IV daily x 5 days

→ then 10 mg IV daily x 5 days

(From DEXA-ARDS trial)

Alternative:
Methylprednisolone 1 mg/kg/day

Benefits:

• Shorter ventilation duration

• Improved oxygenation

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3. COVID-19 ARDS

Indication: SpO₂ < 94% on supplemental oxygen

Medication:

Dexamethasone 6 mg IV/PO daily x 10 days

(RECOVERY trial regimen)

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4. COPD Exacerbation (ICU or ward)

Preferred:

Prednisone 40 mg PO daily x 5 days

If severe or intubated:

Methylprednisolone 40 mg IV q12h

Benefits:

• Faster recovery

• Shorter hospitalization

• Helps reduce inflammation/air trapping

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5. Asthma Exacerbation (Severe)

If unable to tolerate PO:

Methylprednisolone 60–125 mg IV q6h

Once improving:
Switch to oral prednisone 40–60 mg/day → taper

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6. Adrenal Crisis / Acute Adrenal Insufficiency

Symptoms: refractory hypotension, hyponatremia, hyperkalemia, hypoglycemia

Treatment:

Hydrocortisone 100 mg IV bolus

→ then 50 mg IV q6h

Always give BEFORE waiting for cortisol level.

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7. Bacterial Meningitis

(To reduce neurologic complications)

Medication:

Dexamethasone 10 mg IV q6h x 4 days

Must be given BEFORE or WITH the first dose of antibiotics.

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8. Spinal Cord Injury

Modern ICU practice:

• Steroids NOT routinely recommended anymore

• May consider high-dose methylprednisolone in select cases within 8 hours of injury
  (but controversial and high risk of infection)

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9. Pneumocystis pneumonia (PCP) with hypoxia

Indication: PaO₂ < 70 mmHg or A–a gradient > 35

Regimen (Prednisone PO preferred):

• Day 1–5: 40 mg PO BID

• Day 6–10: 40 mg PO daily

• Day 11–21: 20 mg PO daily

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10. Post-extubation Stridor

Medication:

Dexamethasone 5–10 mg IV q6h x 24 hours

Helps reduce laryngeal edema.

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11. ITP / Hemolysis / Autoinflammatory Flares

Examples: warm AIHA, ITP, lupus flare

Common regimen:

• Methylprednisolone 1 mg/kg/day
  or

• High-dose pulse steroids (250–1000 mg/day x 1–3 days for severe autoimmune crises)

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**ICU Steroid Side Effects to Watch

• Hyperglycemia (very common)

• Delirium

• GI bleed (rare → use PPI in high risk)

• Fluid retention

• Infection risk

• Myopathy (prolonged high-dose)

• Poor wound healing

• Sodium retention (with hydrocortisone/fludrocortisone)

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*** ICU PEARLS

• In septic shock, start hydrocortisone ONLY if on significant pressors.

• In ARDS, dexamethasone improves oxygenation and shortens ventilator days.

• Steroid-induced hyperglycemia is common → start insulin protocol early.

• In adrenal crisis never delay steroids while waiting for cortisol.

• For meningitis, give dexamethasone BEFORE antibiotics.

• COPD/asthma: keep steroid courses short.