Treatment is Rapidly Changing – but do not let it sway you from proven critical care therapies!
Steroids
Similar to Voldemort’s Horcruxes, the debate for and against steroid use in ARDS rages just keeps coming back. For a background on steroids in ARDS, take a look at @pulmcrit‘s excellent post on the DEXA-ARDS trial.
What’s the deal with dexamethasone?
The RECOVERY trial was published in the New England Journal of Medicine in July, 2020. In a nutshell, this was a randomized, controlled, open-label trial testing whether dexamethasone reduces death at 28 days in patients hospitalized with COVID-19 when compared to usual care.
My opinion (Allan) is that dexamethasone does show promise in reducing death in patients with COVID-19 and until there are data to disprove the benefit of this drug for patients with COVID-19 then we should strongly consider using it. That being said, it should not take away from quality critical care nursing. That means, we still monitor and treat hyperglycemia, look for signs of pressure sores, wean vasopressors and sedation aggressively, etc. And we keep an eye out for all those side effects that come with steroid use.
High Quality
A randomized controlled trial is considered to be the gold standard of clinical trials.
I’ve included some expert opinion on the RECOVERY trial below:
- @srrezaie from REBELEM
- @pulmcrit from EMcrit and the PulmCrit blog, also the Internet Book of Critical Care
- World Health Organization FAQ
My Advice for Dexamethasone in Critical Care Nursing:
- Watch for hyperglycemia. Steroids cause hyperglycemia and we know patients who have uncontrolled hyperglycemia in critical care have a higher overall morbidity and mortality, but we also don’t want an overly aggressive approach1
- Anticipate an insulin infusion so you can tightly control serum glucose
- Your target should err on the side of higher serum glucose than normal – usually a serum glucose of 8-10 mmol/L
- Have a protocol in place to allow nurses to respond to changes in serum glucose
- I like this template offered by Diabetes Canada starting on page 132
- Dexamethasone was given IV in the RECOVERY trial. So, this is the drug and dose that ideally should be given
- You may see alternatives like methylprednisolone IV or PO or prednisone PO if your shop needs a substitute
- Have a plan to check the patient’s electrolytes
- Steroids will cause hypernatremia and hypokalemia
- Insulin will cause hypokalemia and hypophosphatemia
- I like this pre-printed order set from LSU3
- Look for signs of fluid retention
- Steroids will cause water retention
- This could be dangerous in the setting where patients who are already volume overloaded have low urinary output, and/or receiving high rates of fluid creep from IV flush lines, antibiotics and infusions
- Keep a close eye on the Ins/Outs
- Watch for pressure sores
- This is quality critical care!
- Sometimes pressure sores are unavoidable (eg. patients who do not tolerate a turn or mobility evidenced by objective data points such as hypoxia, hypotension, ventilator-patient dyssynchrony, etc)
- Steroids will thin the epidermis, causing a higher risk of skin breakdown4 – couple steroids with critical illness and muscular atrophy from ICU acquired weakness and you have a recipe for a pressure sore that may cause sepsis down the road
- I hang dexamethasone in a 25 ml bag of NS to minimize fluid creep
- This is an evidence free zone…
- If your patient is unable to tolerate excess volume, I mix my dexamethasone 6 mg in a 25 ml bag of NS and run it over half an hour
- Editor @matthewjdouma prefers giving dexamethasone IV push:
Good content, definitely passes review from my perspective. Love the LSU preprint orders, I love seeing other shops’ orders. My preference for admin is IVP undiluted (4 mg/mL or 10 mg/mL) over 1 minute. doses >8 mg admin slow/several min. #FOANed
— Matthew J Douma (@matthewjdouma) July 25, 2020
References
1. Griesdale DE, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ. 2009;180(8):821-827. doi:10.1503/cmaj.090206
2. https://guidelines.diabetes.ca/docs/resources/in-hospital-management-clinical-order-set-fillable.pdf
great information.