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Preadmission Oral Corticosteroids Are Associated with Reduced Risk of Acute Respiratory Distress Syndrome in Critically Ill Adults with Sepsis
McKown AC, McGuinn EM, Ware LB, et al. Crit Care Med. 2017; 45: 774-80.
Study Question: Do preadmission corticosteroids reduce the risk of acute respiratory distress syndrome (ARDS) in patients with sepsis?
Study Description: This was a retrospective, single-center study of adult patients enrolled in the Validating Acute Lung Injury Markers for Diagnosis (VALID) study. Included patients met the 2001 definition for sepsis, and the American-European Consensus Conference definition of acute lung injury (ALI) within 96 hours of ICU admission. The primary outcome was the presence of ALI within 96 hours of ICU admission, which was prospectively adjudicated by two physicians. Due to the similarity of the ALI definition to the Berlin ARDS definition, they considered these patients to have ARDS.
Results: A total of 915 patients were enrolled in the no steroid group compared to 165 patients in the steroid group. Median baseline Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 27 (IQR 21-33) and 29 (IQR 23-34), for the no steroid and steroid groups, respectively. Patients receiving preadmission steroids were most commonly prescribed steroids for transplant (33%), autoimmune disease (24%) and hematologic malignancy (21%). After adjusting for pre-specified confounders in a multivariate analysis, patients with preadmission corticosteroids had a lower incidence of ARDS compared to the no steroid group (OR 0.53, 95% CI 0.33-0.84; 0.008). An additional sensitivity analysis excluding patients with malignancy, hematopoietic stem cell transplant and solid organ transplant also showed a decrease in ARDS (OR 0.44, 95% CI 0.21-0.94; p=0.034). Finally, higher doses of preadmission steroids (30 mg prednisone equivalent) compared to lower doses of 5 mg, were also associated with a lower incidence of ARDS (OR 0.53, 95% CI 0.32-0.86; p=0.020). There was no difference in in-hospital mortality, ICU LOS or ventilator-free days.
Conclusion(s): Preadmission corticosteroids were associated with a reduction of the occurrence of ARDS in patients with sepsis.
Perspective: The authors aimed to evaluate the effect of preadmission steroid administration on the development of ARDS and hypothesize that early administration of corticosteroids may play a role in ARDS prevention. The authors did multiple sensitivity analyses and a multivariate logistic regression to ensure that confounding variables were taken into consideration given the differences between the groups at baseline and the smaller sample size of the preadmission steroid group. Despite the lower incidence of ARDS, there was no difference in clinical outcomes such as ICU LOS or ventilator-free days. Questions regarding the role of steroids in ARDS continue to remain such as the optimal dose of corticosteroids and if early initiation in a high-risk population after hospital admission can reduce progression of illness to ARDS.