title: 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.
  
  
  METHODS
  Self-administered paper survey.
  
  
  METHODS
  Intensivists in academic hospitals with clinical trial expertise in critical illness.
  
  
  METHODS
  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 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.
  
  
  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 vasopressor-refractory 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 corticosteroid-responsive 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.
authors.affiliation: Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca
authors.forename: François
authors.initials: F
authors.lastname: Lamontagne
authors.forename: Hector
authors.initials: H
authors.lastname: Quiroz Martinez
authors.forename: Neill K J
authors.initials: NK
authors.lastname: Adhikari
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cook
authors.forename: Karen K Y
authors.initials: KK
authors.lastname: Koo
authors.forename: François
authors.initials: F
authors.lastname: Lauzier
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Kho
authors.forename: Karen E A
authors.initials: KE
authors.lastname: Burns
authors.forename: Clarence
authors.initials: C
authors.lastname: Chant
authors.forename: Rob
authors.initials: R
authors.lastname: Fowler
authors.forename: Ivor
authors.initials: I
authors.lastname: Douglas
authors.forename: Yannick
authors.initials: Y
authors.lastname: Poulin
authors.forename: Karen
authors.initials: K
authors.lastname: Choong
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.forename: Maureen O
authors.initials: MO
authors.lastname: Meade
mesh_terms: D055371:Acute Lung Injury / Q000188:drug therapy; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000309:Adrenal Insufficiency / Q000188:drug therapy; D000776:Anesthesiology; D001291:Attitude of Health Personnel; D001986:Bronchial Spasm / Q000188:drug therapy; D017714:Community-Acquired Infections / Q000188:drug therapy; D003240:Connective Tissue Diseases / Q000188:drug therapy; D000075202:Contraindications; D003422:Critical Care; D016638:Critical Illness; D018549:Cryptogenic Organizing Pneumonia / Q000188:drug therapy; D013502:General Surgery; D006801:Humans; D007022:Hypotension / Q000188:drug therapy; D007388:Internal Medicine; D011014:Pneumonia / Q000188:drug therapy; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy; D015272:Pulmonary Medicine; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000188:drug therapy; D057566:Self Report; D012772:Shock, Septic / Q000188:drug therapy; D011795:Surveys and Questionnaires
chemical_list: D000305:Adrenal Cortex Hormones