ICU Corticosteroids — Comprehensive Pharmacology (Glucocorticoids in Critical Illness)

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• Adrenal crisis therapy is rapid IV hydrocortisone — 100 mg bolus then 200 mg/24 h (continuous infusion or 50 mg every 6 h) plus 0.9% saline, with fludrocortisone added for primary adrenal insufficiency (Endocrine Society / secondary-adrenal-crisis guidance) — give EMPIRICALLY, do not wait for the cortisol level, and do not substitute dexamethasone
• Corticosteroid administration is an independent predictor of ICU-acquired paresis (OR 14.90 in a prospective multicentre study of ventilated patients); the historical association with neuromuscular blocking agents is dose- and duration-dependent — minimise exposure to both, especially together
• Adrenal insufficiency after systemic corticosteroids -- risk rises with dose and duration and no route, dose or duration makes it impossible to exclude (meta-analysis); cessation or dose reduction, infection or surgery can precipitate adrenal crisis (hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia, lethargy). NEVER stop long-term steroids abruptly -- taper and give stress-dose cover
• Corticosteroids coadministered with NSAIDs is a high-risk characteristic for corticosteroid-induced peptic ulcer (small but highly probable association) — avoid the combination in ICU; use paracetamol/opioids for analgesia in patients on steroids
• ADRENAL trial: hydrocortisone 200 mg/day did NOT reduce 90-day mortality in ventilated septic shock (27.9% vs 28.8%) — it sped shock resolution (median 3 vs 4 days) and shortened the initial ventilation episode. Reserve for shock REFRACTORY to adequate fluids + vasopressors, NOT all septic shock