From the Guidelines
Critical Illness-Related Corticosteroid Insufficiency (CIRCI) is a condition characterized by inadequate intracellular glucocorticoid-mediated anti-inflammatory activity for the severity of the patient’s critical illness.
Definition and Diagnosis
- CIRCI is associated with increased circulating levels of biological markers of inflammation and coagulation over time, morbidity, length of intensive care unit (ICU) stay, and mortality 1.
- The diagnosis of CIRCI is challenging, and no single test can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of <9 μg/dl) after cosyntropin (250 μg) administration and a random plasma cortisol of <10 μg/dl may be used by clinicians 2.
Clinical Presentation
- Putative signs and symptoms of CIRCI include fever, asthenia, confusion, delirium, coma, hypotension refractory to fluid resuscitation, decreased sensitivity to catecholamines, high cardiac index, nausea, vomiting, intolerance to enteral nutrition, persistent hypoxia, hypoglycemia, hyponatremia, hyperkalemia, metabolic acidosis, and hypereosinophilia 1.
Treatment
- Intravenous hydrocortisone <400 mg/day for ≥3 days at full dose may be used in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy 2.
- IV methylprednisolone 1 mg/kg/day may be used in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) 2.
- Corticosteroids are not suggested for patients with major trauma or adult patients with sepsis without shock 2.
From the Research
Definition and Pathogenesis of CIRCI
- Critical Illness-Related Corticosteroid Insufficiency (CIRCI) is characterized by hypothalamic-adrenal axis insufficiency following acute medical conditions, such as sepsis, septic shock, and acute respiratory distress syndrome 3.
- CIRCI is caused by adrenal insufficiency, tissue corticosteroid resistance, and is characterized by an exaggerated and protracted proinflammatory response 4.
- The pathogenesis of CIRCI involves dysregulation of the hypothalamic-pituitary-adrenal axis, altered cortisol metabolism, and tissue resistance to glucocorticoids 5.
Clinical Presentation and Diagnosis of CIRCI
- CIRCI should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents, particularly in the setting of sepsis 4.
- The diagnosis of CIRCI is challenging, and the use of delta total serum cortisol and random total cortisol levels can be helpful in identifying patients with adrenal insufficiency 4, 6.
- The role of corticosteroids in the management of CIRCI is still debated, and the diagnosis and treatment of CIRCI may vary among clinicians due to inconsistent high-quality study results 3, 6.
Management and Treatment of CIRCI
- The management of CIRCI involves the use of corticosteroids, such as hydrocortisone, in patients with septic shock and acute respiratory distress syndrome 4, 7.
- The dose and duration of corticosteroid therapy in CIRCI are still debated, and further studies are needed to determine the optimal treatment strategy 4, 5.
- The use of mineralocorticoids, such as fludrocortisone, may also be beneficial in patients with CIRCI, particularly in those with hyperreninemic hypoaldosteronism 7.