Corticosteroids for critically ill COVID-19 patients with cytokine release syndrome: a limited case series
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CORRESPONDENCE
Corticosteroids for critically ill COVID-19 patients with cytokine release syndrome: a limited case series Stephen Su Yang, MDCM, FRCPC
. Jed Lipes, MDCM, FRCPC
Received: 27 April 2020 / Revised: 27 April 2020 / Accepted: 29 April 2020 Ó Canadian Anesthesiologists’ Society 2020
To the Editor, Approximately 5% of coronavirus disease (COVID-19) patients will require admission to an intensive care unit (ICU).1 Among these patients, the most severe cases may be mediated by a late-onset systemic inflammatory response with cytokine dysregulation referred to as cytokine release syndrome (CRS).2 Clinically, this results in fever, acute respiratory distress syndrome, multiorgan failure, and/or hemodynamic collapse due to distributive shock. Late-onset severe COVID-19 patients may respond to anti-inflammatory therapy without worsening the initial early viral infection.3 We describe a case series of 15 COVID-19 patients admitted to ICU who received corticosteroids in the context of CRS. Cytokine release syndrome was identified as worsening hypoxemia or vasoplegia with rising C-reactive protein (CRP) or interleukin-6 levels without alternative clinical explanation. The Research Ethics Board at our local site approved this retrospective case series. The characteristics of these patients are provided in the Table. The median [interquartile range (IQR)] age was 72 [62-74] yr (range, 45-75 yr), and nine of the 15 patients (60%) were male. The indications for steroid
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12630-020-01700-w) contains supplementary material, which is available to authorized users. S. S. Yang, MDCM, FRCPC (&) Department of Anesthesia, Jewish General Hospital, Montreal, QC, Canada e-mail: [email protected] J. Lipes, MDCM, FRCPC Department of Internal Medicine, Jewish General Hospital, Montreal, QC, Canada
administration were hypoxic respiratory failure (67%), vasoplegic shock on multiple vasopressors (20%), or both respiratory and cardiovascular failure (20%). Two nonintubated patients received steroids for impending respiratory failure with increasing inflammatory markers concerning for CRS. The median [IQR] day of steroid administration after symptoms onset was 14 [12–15] days. Nine patients (60%) received methylprednisolone, four patients (27%) received hydrocortisone, and two patients (13%) received dexamethasone. The median [IQR] dose of corticosteroids during the first 24 hr in methylprednisolone equivalents was 160 [83-160] mg. In almost all cases, there was a decrease in vasopressor requirement or an improvement in oxygenation after steroid administration. There was an average fall in CRP of 236 mgL-1 with steroid administration (eFig. 1, available as Electronic Supplementary Material [ESM]). An average increase in the arterial partial pressure of oxygen/fraction of inspired oxygen (i.e., P/F) ratio of 44 was detected 24 hr after steroid administration (eFig. 2, available as ESM). Currently, four patients were discharged hom
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