1. Hemodynamic Support Measures

Relative adrenal insufficiency leads to profound vascular hyporesponsiveness to endogenous catecholamines and significant intravascular volume depletion. The cornerstone of management is rapid fluid resuscitation, followed by the prompt initiation of targeted vasopressors and stress-dose corticosteroids to restore tissue perfusion.

Vasopressor and Corticosteroid Selection

The primary indication for these therapies is fluid-refractory hypotension, defined as a mean arterial pressure (MAP) below 65 mm Hg after an initial crystalloid bolus of 30 mL/kg.

2. Prevention of ICU-Related Complications

The use of stress-dose steroids, while life-saving, can exacerbate common ICU complications by causing hyperglycemia, impairing mucosal defenses, and suppressing the immune system. Proactive, evidence-based protocols are essential to reduce morbidity.

Hyperglycemia Management

• Target Blood Glucose: Maintain a range of 140–180 mg/dL.
• Method: Use an algorithmic continuous insulin infusion (e.g., Yale protocol) with point-of-care glucose checks every 1–2 hours.
• Pitfall: Avoid relying on sliding-scale insulin alone, as it is associated with increased glycemic variability and poor control.

Stress Ulcer Prophylaxis (SUP)

• Agents: Proton pump inhibitors (PPIs) like Pantoprazole 40 mg IV daily, or H₂-receptor antagonists (H₂RAs) like Famotidine 20 mg IV every 12 hours.
• Indications: High-risk patients, including those on mechanical ventilation for >48 hours, those with coagulopathy, or those receiving high-dose steroids.
• Monitoring: Watch for signs of gastrointestinal bleeding and consider testing for Clostridioides difficile if diarrhea develops.

Infection Surveillance & Prophylaxis

• Strict adherence to Ventilator-Associated Pneumonia (VAP) and Central Line-Associated Bloodstream Infection (CLABSI) prevention bundles.
• Daily evaluation of all invasive lines and devices for necessity and signs of infection.
• Practice antimicrobial stewardship by de-escalating antibiotics when appropriate. Consider antifungal prophylaxis only in select, very high-risk patients.

3. Management of Corticosteroid Adverse Effects

Prolonged use of high-dose steroids carries significant risks, including metabolic derangements, opportunistic infections, myopathy, and gastrointestinal bleeding. A strategy focused on dose minimization and vigilant supportive care is required to mitigate these effects.

Hyperglycemia

Continue the insulin infusion as needed, maintaining moderate blood glucose targets. Monitor closely for hypoglycemia, especially as the steroid dose is tapered and the patient’s inflammatory state resolves.

Infection

Avoid routine systemic antibiotic prophylaxis. Instead, tailor infection prevention strategies to individual patient risks. Ensure vaccinations (e.g., influenza, pneumococcal) are updated once the patient is stable and approaching discharge. Daily sedation interruptions and early mobilization are key strategies to lower VAP risk.

Myopathy & GI Bleeding

The primary mitigation strategy is to employ the lowest effective glucocorticoid dose for the shortest possible duration. Initiate a rapid taper as soon as the patient is hemodynamically stable off vasopressors. Continue stress ulcer prophylaxis while the patient remains at high risk, and assess muscle strength and mobility daily to screen for critical illness myopathy.

4. Multidisciplinary Goals-of-Care Discussions

The decision to continue or taper prolonged corticosteroid therapy in critical illness is complex. It requires early, structured communication among the care team, patient, and family to align interventions with patient-centered goals and minimize iatrogenic harm.

Team Composition

Effective discussions should involve a multidisciplinary team, including critical care physicians, clinical pharmacists, palliative care specialists, bedside nursing staff, and rehabilitation therapists.

Discussion Focus

• Clearly outline the expected benefits versus the ongoing risks of steroid therapy.
• Establish a clear taper plan with defined monitoring checkpoints and criteria for pausing or restarting therapy.
• Provide comprehensive patient and family education on discharge, including instructions for emergency steroid injection techniques and the importance of medical alert identification.