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Correspondence and Brief Communications
September 1, 2006

Using Corticosteroids in Intensive Care

Paul E. Marik, MD; Djillali Annane, MD; Charles L. Sprung, MD; et al Wiebke Arlt, MD; Didier Keh, MD; International Task Force on the Diagnoses and Management of Adrenal Insufficiency in the Critically Ill
Arch Surg. 2006;141(9):946-947. doi:10.1001/archsurg.141.9.946

We read the study by Britt et al1 on the use of corticosteroids in the intensive care unit and the accompanying critique with much interest. The article has a number of serious methodological issues that render the results of the study difficult to interpret. Most importantly, the authors did not report the dose (in hydrocortisone equivalents) of corticosteroid the patients received, nor did they stratify the patients into “high” and “low” dose groups.2-5 This is critically important because the “mega-industrial” dose of corticosteroid used for acute spinal cord injuries (equivalent to approximately 50 000 mg of hydrocortisone) is potently immunosuppressive and myolytic and associated with an increased risk of secondary infections and myopathy.4,6 Conversely, the low dosage of corticosteroid (200-300 mg of hydrocortisone per day) used to restore the balance between the dysregulated proinflammatory and anti-inflammatory response in patients with septic shock and acute respiratory distress syndrome does not cause immune paresis or interfere with wound healing.7-9 Indeed, an increased risk of secondary infections and myopathy has not been reported with the use of low doses of corticosteroids.