corticosteroidsintheicu-McGillUniversity.docVIP

CORTICOSTEROIDS IN THE ICU: D. P. Laporta MD the whole truth Pulmonary and Critical Care June 1997 Sir MBD - Jewish General Hospital, McGill University PRO Montreal, Quebec REFERENCES- REVIEWS Steroids and biologic agents in the ICU. RP Allen, Crit Care Clinics, July 1991:695-712 Adrenal crisis. R Chin, Critical Care Clinics January 1991:23-42 The utility of parenteral glucocorticoids in the emergency department. Hoang KD , Pollack CV Jr, J Emerg Med 1994; 12:507-19 OBJECTIVE To establish the evidence to justify the use of systemic corticosteroids (SCS) in specific clinical situations in the ICU. Specific recommendations are made from a critical review of the literature. METHODS Clinical Experience SMMBD-JGH ICU Database ICU Textbooks (Shoemaker, Civetta, Rippe) Evaluation of Published Literature1: Human, Clinical Trials, Reviews (Systematic, Narrative) Not Used: Animal / Physiologic Studies 1 EVALUATION OF PUBLISHED STUDIES ON SCS IN THE ICU 1. Internal validity Randomized, blinded. control group, similar at outset, treated similarly, inclusion/exclusion criteria 2. Results: treatment effect (how large, incl burden (side effects)), outcome measures, followup, comorbid illness 3. Generalizability (external validity) 4. Evaluation of literature (grading2) 5. Recommendations3 2 GRADING of clinical studies 3 RECOMMENDATION I evidence from ? 1 RCT, low FP FN GOOD evidence to support II evidence from ? 1 RCT, high FP ? FN MODERATE evidence to support III non-randomized cohort comparisons POOR evidence to support IV non-randomized historical cohort comparisons ? V case-series (no controls) ? *specific clause if high-quality overview (systematic review)  SCS IN THE ICU: CLINICAL INDICATIONS GRADE RECOMMENDATION USE DON?T Adrenal cortical insufficiency V POOR ? Asthma I GOOD ? COPD II-III MOD-POOR ? Sepsis/septic shock I GOOD ? Acute bacterial meningitis II MOD