Corticosteroid use in the intensive care unit: a survey of intensivists

Abstract

Objective The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. Design Self-administered paper survey.Population Intensivists in academic hospitals with clinical trial expertise in critical illness. Measurements We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected -013-9929-3 North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids. Main results Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressorrefractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroidresponsive illnesses (85%). Conclusions Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.123 Can J Anesth/J Can Anesth (2013) 60:652-659 DOI 10.1007/s12630 RésuméObjectif L'efficacite´des corticoste´roı¨des syste´miques demeure incertaine pour plusieurs maladies graves. Notre objectif primaire e´tait d'obtenir l'opinion des intensivistes en Ame´rique du Nord concernant leur perception de l'utilisation des corticoste´roı¨des dans la pratique clinique. Méthodologie Sondage auto-administre´sur papier. Population Intensivistes dans des hôpitaux universitaires ayant une expertise en matie`re d'e´tudes cliniques sur les maladies graves. Mesures Les e´le´ments du questionnaire ont e´te´cre´e´s dans des groupes de discussion; nous les ...

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