Fig. 5.

Protocol for prolonged methylprednisolone treatment in patients with early ARDS. This protocol was recommended in the 2017 guidelines of the Multispecialty Task Force of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (Supplemental Digital Content 5, https://links.lww.com/CCM/C918) [35] Vitamin supplementation was not part of the recommended protocol. The dosage is adjusted to ideal body weight and rounded up to the nearest 10 mg (e.g., 77 mg rounded up to 80 mg). Thereafter I would state that 80 mg is an example for a patient with an ideal body weight of 77. Day 0, intravenous bolus (80 mg in 50 cc normal saline) over 30 min. Day 0-to ICU discharge: infusion is done by adding the daily dosage to 240 cc of normal saline and running it at 10 cc/h. If necessary, infusion can be changed to bolus every 6 h (1/4 daily dose) or in the last 6 days to every 12 h (1/2 daily dose). If on day 3–5 there is no improvement or even worsening oxygenation indices the condition is considered “unresolving ARDS”. In this case, a protocol of similar duration of treatment, but with double the daily dose of methylprednisolone (starting with 160 mg/day) is initiated. If the patient is extubated before day 14, the methylprednisolone infusion is advanced to day 15 of drug therapy and tapered according to schedule. Oral administration should be delayed to 5 days after extubation, because enteral absorption of methylprednisolone, and likely other GCs, is compromised for days after extubation. Rapid tapering can be associated with rebound systemic inflammation in the presence of suppressed adrenal function with worsening of lung physiology and an increased mortality risk [60]. If patients worsen significantly, then GC treatment should be restarted again, and after improvement followed by slow tapering, to comply with the Food and Drug Administration’s package insert warnings (Reference ID: 3,032,293) [61]. Vitamin supplementation: ascorbic acid 1.5 g every 6 h mixed in 100 ml saline solution × 4 doses per day; thiamine 100 mg every 12 h mixed in 100 ml dextrose 5% in water × 2 doses per day; vitamin D 480,000 IU dose (30 ml) × 1 dose. Recheck vitamin D level on day 5; if low, supplement 96,000 IU/day for 5 days