Efficacy and safety of corticosteroids in critically ill patients: a systematic review and meta-analysis.

Summary

This meta-analysis of 43 RCTs (n=10,853) shows corticosteroids reduce short-term mortality (RR 0.85) and improve key ventilatory and length-of-stay outcomes in critically ill patients, including those with ARDS. Benefits were greatest with early (≤72 h), low-dose, and prolonged (≥7 days) regimens; hydrocortisone plus fludrocortisone may benefit septic shock.

Key Findings

• Corticosteroids reduced short-term mortality versus placebo (RR 0.85; 95% CI 0.77-0.94).
• Reduced ICU length of stay (MD −2.02 days), hospital stay (MD −2.66 days), and duration of mechanical ventilation (MD −4.24 days).
• Increased ventilator-free days at 28 days (MD +2.83) and improved oxygenation index.
• Greatest benefits with early (≤72 h), low-dose (<400 mg/day hydrocortisone equivalent), and prolonged (≥7 days) regimens.

Clinical Implications

Consider early, low-dose, prolonged corticosteroids in severe CAP and ARDS phenotypes while monitoring for adverse effects; hydrocortisone plus fludrocortisone may be considered in septic shock pending further direct comparisons.

Limitations

• Heterogeneity in populations, dosing regimens, and co-interventions; incomplete reporting of some indices (e.g., heterogeneity statistic truncated in abstract).
• Potential publication bias and varying definitions of outcomes across trials.

Future Directions

Prospective trials to refine dose, duration, and timing by ARDS/CAP phenotypes; head-to-head comparisons of hydrocortisone vs hydrocortisone plus fludrocortisone; integration with biomarker-guided strategies.