Critical Care Guideline Changes Boost Corticosteroid Uses, Role of Families

PHOENIX — The Society of Critical Care Medicine (SCCM) revealed updates to guidelines regarding the use of corticosteroids and glycemic control in critical illness along with a new guideline on recognizing and responding to clinical deterioration outside the intensive care unit (ICU).

All three documents were published in Critical Care Medicine and presented at the SCCM Critical Care Congress.

Use of Corticosteroids

The focused update to guidelines for corticosteroids in sepsis, acute respiratory distress syndrome (ARDS), and community-acquired pneumonia (CAP), changed several recommendations from the 2017 iteration based on more recent evidence.

Based on moderate-quality evidence, the society gave a strong recommendation for administering corticosteroids to patients who have been hospitalized with severe bacterial CAP, which was an upgrade from the prior conditional recommendation. SCCM made no recommendations regarding the administration of corticosteroids to adults who were hospitalized with less severe cases of bacterial CAP.

Corticosteroids also got a conditional recommendation for use in adults critically ill with ARDS in the update, which broadened the suggested use from just those with early moderate to severe ARDS.

For adults in septic shock, corticosteroids were suggested with a conditional recommendation based on lower-quality evidence, reversing course from the suggestion against use in the 2017 guidelines. However, the society added a recommendation against administering high-dose/short-duration corticosteroids, here defined as being greater than 400 mg per day of a hydrocortisone equivalent for less than 3 days. This was a strong recommendation based on a moderate certainty of evidence. Previously, use was suggested for patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy.

Presenter Stephen Pastores, MD, of Memorial Sloan Kettering Cancer Center in New York City, stressed the importance of two guidelines in particular — the use of corticosteroids in patients experiencing septic shock and the recommendation against using high-dose/short-duration corticosteroids. He also encouraged more research in order to address areas where either suggestions or no recommendations were provided due to a lack of supporting evidence.

There are “still a lot of knowledge gaps, which hopefully we’re starting to answer in the coming years, And hopefully, with the next version of the guidelines, we will have some of these knowledge gaps already answered,” he told MedPage Today.

Glycemic Control in the ICU

An update to the glycemic control guidelines for critically ill adults and children, last revised in 2012, changed the insulin infusion recommendations and gave endorsement to explicit decision support tools.

For adults, the society reiterated that providers should initiate low-risk glycemic management measures “without delay” and should begin both glycemic management protocols and procedures as a treatment measure for persistent hyperglycemia of 10 mmol/L (180 mg/dL) or more in critically ill adult and pediatric patients.

For both adults and children, the panel suggested against titrating insulin infusion to a lower blood glucose target in the 4.4-7.7 mmol/L (80-139 mg/dL) range compared to a higher blood glucose target range of 7.8-11.1 mmol/L (140-200 mg/dL) in order to reduce hypoglycemia risks.

No recommendation had previously been made for pediatric critical care patients, and the adult guidelines had left the target as generally under 150 mg/dL and absolutely below 180 mg/dL with a protocol that would achieve a low hypoglycemia rate.

Explicit decision support tools were suggested with a conditional recommendation for both adult and pediatric ICU patients when giving IV insulin.

One of the presenters Judith Jacobi, PharmD, BCCCP, a retired critical care pharmacist and past president of the SCCM, stressed to the audience the importance of using the new guidelines to examine and update current healthcare practices.

“One of the big takeaways is that we want you to go home and evaluate your glycemic protocols — maybe you haven’t looked at them in a long time,” she said. “Explicit decision support successions apply to both adults and children. And we hope that that guidance will help you select a robust product to use for your patient monitoring.”

Clinical Deterioration Outside the ICU

SCCM issued a new guideline for recognizing and responding to clinical deterioration outside the ICU.

In it, the society encouraged the incorporation of families into care practices, suggesting that family and partner concerns be utilized as part of hospital early warning systems, as these individuals should be able to recognize the differences in a patient’s clinical status that may indicate deterioration, and then alert care staff.

Rather than making a recommendation on universal continuous vital sign monitoring, the document called for focused education for direct-care, non-ICU hospital clinicians regarding how to recognize early clinical deterioration.

Another recommendation included the hospital-wide deployment of a rapid response team/medical emergency team for non-ICU patients, with explicit activation criteria. No recommendation of which professionals should be on the team was made, but responding clinicians should have a level of expertise in asking about and understanding patients’ goals of care and then in building a treatment plan that best reflects those goals.

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