When to treat for critical illness-related adrenal insufficiency?

From the Guidelines

Treatment for critical illness-related adrenal insufficiency should be initiated in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy.

Key Considerations

• The diagnosis of critical illness-related corticosteroid insufficiency (CIRCI) is complex and not solely based on a single test, but rather a combination of clinical signs and symptoms, such as hypotension refractory to fluid resuscitation, decreased sensitivity to catecholamines, and persistent hypoxia 1.
• The use of intravenous hydrocortisone at a dose of <400 mg/day for ≥3 days is suggested for patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy 1.
• Corticosteroids are not suggested for adult patients with sepsis without shock 1.
• In patients with early moderate to severe acute respiratory distress syndrome, the use of IV methylprednisolone 1 mg/kg/day is suggested 1.
• The 250-μg ACTH stimulation test may be used to diagnose CIRCI, but its use is not universally recommended due to limited evidence 1.

Clinical Decision-Making

• Clinicians should consider the patient's overall clinical presentation, including signs and symptoms of CIRCI, when deciding whether to initiate treatment with corticosteroids.
• The use of corticosteroids should be individualized and based on the patient's specific condition and response to treatment.
• Regular monitoring of the patient's hemodynamic status and response to treatment is essential to guide clinical decision-making 1.

From the Research

Diagnosis and Treatment of Critical Illness-Related Adrenal Insufficiency

• The diagnosis of critical illness-related adrenal insufficiency is complex and requires careful evaluation of the patient's condition 2, 3.
• The concept of relative adrenal insufficiency has multiple pathophysiologic flaws and is not supported by current evidence 3.
• Patients with septic shock who are pressor dependent or refractory to fluid resuscitation may receive a short course of hydrocortisone regardless of their serum cortisol levels or their response to a cosyntropin stimulation test (CST) 2, 3.
• Adrenal insufficiency in critically ill patients is best diagnosed by a delta total serum cortisol of < 9 microg/dL after adrenocorticotrophic hormone (250 microg) administration or a random total cortisol of < 10 microg/dL 2.
• The benefit of treatment with glucocorticoids seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (PaO2/FiO2 of < 200 and within 14 days of onset) 2.

Timing of Treatment

• Treatment with hydrocortisone should be considered in patients with septic shock who are pressor dependent or refractory to fluid resuscitation, regardless of their serum cortisol levels or their response to a CST 2, 3.
• The duration of treatment with hydrocortisone is typically for > or = 7 days in patients with septic shock 2.
• Glucocorticoids should be weaned and not stopped abruptly, and reinstitution of treatment should be considered with recurrence of signs of sepsis, hypotension, or worsening oxygenation 2.

Special Considerations

• The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation 2.
• The concept of critical illness-related corticosteroid insufficiency (CIRCI) is still evolving, and further research is needed to understand its pathophysiology and optimal treatment 4, 5, 6.