Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI)
For patients with septic shock that is not responsive to fluid resuscitation and moderate-to-high-dose vasopressor therapy, intravenous hydrocortisone <400 mg/day should be administered for at least 3 days at full dose, with a total treatment duration of 7-14 days depending on clinical response. 1, 2
Diagnosis of CIRCI
While there is no single definitive test for CIRCI, the following diagnostic approaches may be used:
- Delta cortisol (change in baseline cortisol at 60 min of <9 μg/dL) after cosyntropin (250 μg) administration 1, 3
- Random plasma cortisol of <10 μg/dL 1, 3
- Plasma free cortisol or salivary cortisol levels are not recommended over plasma total cortisol 1
- Corticotropin levels are not recommended for routine diagnosis 1
Clinical Features Suggestive of CIRCI
- Cardiovascular: Hypotension refractory to fluid resuscitation, decreased sensitivity to catecholamines, high cardiac index 1
- Neurological: Confusion, delirium, coma 1
- Respiratory: Persistent hypoxia 1
- Laboratory: Hypoglycemia, hyponatremia, hyperkalemia, metabolic acidosis, hypereosinophilia 1
- Digestive: Nausea, vomiting, intolerance to enteral nutrition 1
Treatment Recommendations by Condition
1. Septic Shock
- Recommendation: IV hydrocortisone <400 mg/day for ≥3 days at full dose 1
- Dosing: 200 mg/day in four divided doses or as a continuous infusion of 240 mg/day (10 mg/hr) 3
- Duration: 7-14 days total, depending on clinical response 2
- Monitoring: Watch for hyperglycemia, hypernatremia, and hypokalemia 2
2. Sepsis without Shock
- Recommendation: Corticosteroids are not recommended 1
- Evidence: No mortality benefit and potential for harm 1
3. Acute Respiratory Distress Syndrome (ARDS)
- Recommendation: IV methylprednisolone 1 mg/kg/day for patients with early moderate to severe ARDS (PaO2/FiO2 <200 and within 14 days of onset) 1
- Duration: ≥14 days 3
- Important note: Slow tapering (6-14 days) is recommended rather than rapid discontinuation (2-4 days) to prevent inflammatory rebound 1
4. Community-Acquired Pneumonia (CAP)
- Recommendation: Corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent 1
- Benefits: Shortened hospital stay, reduced need for mechanical ventilation, prevention of ARDS 1
- Risk: Increased risk of hyperglycemia 1
5. Major Trauma
- Recommendation: Corticosteroids are not recommended 1
- Evidence: No mortality benefit and potential for harm 1
6. Influenza
- Recommendation: Corticosteroids are not recommended 1
- Evidence: Associated with increased mortality 1
Tapering Recommendations
- For ARDS: Slow tapering over 6-14 days rather than rapid discontinuation 1
- For courses >14 days: Gradual reduction is particularly important to prevent adrenal insufficiency 2
- For patients who deteriorate after stopping corticosteroids: Consider reinitiating therapy 2
Monitoring During Treatment
- Monitor for hyperglycemia (most common adverse event) 1, 2
- Watch for secondary infections, though risk is not significantly increased with short-term use 1
- Monitor for signs of adrenal insufficiency when tapering or discontinuing 2
- Enhanced infection surveillance is recommended, especially in ARDS patients, as glucocorticoid treatment can blunt febrile response 1
Important Caveats
- CIRCI is characterized by dysregulated systemic inflammation resulting from inadequate intracellular glucocorticoid-mediated anti-inflammatory activity 1
- The condition is associated with increased morbidity, ICU length of stay, and mortality 1
- Treatment decisions should be based on the specific clinical condition rather than a general approach to all critically ill patients 1
- Dexamethasone is not recommended for the treatment of CIRCI 3
- Abrupt discontinuation of corticosteroids should be avoided to prevent inflammatory rebound 1, 2