Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: Consensus statements from an international task force by the American College of Critical Care Medicine (original) (raw)
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Journal of the ASEAN Federation of Endocrine Societies, 2022
Objectives. The diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) remains a challenge. This initiative aimed to develop a protocol for the diagnosis and management of CIRCI which will facilitate informed decision-making among clinicians through consensus-building among a multidisciplinary team. Methodology. This was a single-center, qualitative study which utilized the modified Delphi method, consisting of a sequential iterative process with two rounds of voting. A cutoff value of 70% was set as the threshold for reaching consensus. Results. The protocol on the diagnosis and management of CIRCI was approved after two rounds of voting, with all the components reaching 83.3%-100% agreement. This protocol on CIRCI provided a framework for the clinical approach to refractory shock. It was advocated that all cases of probable CIRCI should immediately be started on hydrocortisone at 200 mg/day. The definitive diagnosis of CIRCI is established through a random serum cortisol <10 mcg/dL or increase in cortisol of <9 mcg/dL at 60 minutes after a 250 mcg ACTH stimulation test in patients with indeterminate random cortisol levels. Conclusion. The presence of refractory shock unresponsive to fluid resuscitation and vasopressors should warrant the clinical suspicion for the existence of CIRCI and should trigger a cascade of management strategies.
Critical care medicine, 2017
To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of th...
Acta medica Philippina, 2022
Introduction. A significant number of critically ill patients, as high as 60% among patients with septic shock, suffer from critical illness-related corticosteroid insufficiency (CIRCI), which refers to an inadequate corticosteroid response to the level of stress. Objectives. This study aimed to determine the strategies employed in managing patients with critical illness-related corticosteroid insufficiency and the outcomes of these patients at a tertiary hospital. Methods. This was a single-center, mixed-methods study which consisted of a review of charts of patients 19 years old and above admitted for shock or developed refractory hypotension from January 2017-December 2019, and key informant interviews and focus group discussion among clinicians who have experience in managing CIRCI. Results. A total number of 362 patient charts reviewed showed a relatively low rate of initiation of corticosteroids for patients with refractory shock, at just 28.57% of the entire population. After corticosteroids were initiated, patients were in shock for a median of just one day and the median blood pressure improved to 100/60 mm Hg. In this cohort, patients who were started on steroids had more severe illness, as measured by the Mortality Probability Model (MPM) score, which had a median of 43.65% for the group on steroids and just 25.0% for the non-steroid group (p ≤ 0.0001). Patients who were started on steroids had a statistically significant longer median days on a ventilator, 5 days vs. 3 days for the non-steroid group (p = 0.0297); longer median length of intensive care unit (ICU) stay, 8 days vs. 5 days for the non-steroid group (p = 0.0410), and a higher morbidity and mortality rate. The need for steroids, the presence of septic shock, and a higher MPM score were significant predictors of mortality. Discussions among clinicians revealed significant variability in practices in the management of CIRCI. Conclusion. The presence of clinical features of CIRCI is a poor prognostic factor. Timely recognition, work-up, and interventions to address CIRCI are paramount in critical care.
American Journal of Respiratory and Critical Care Medicine, 2014
Rationale: Studies evaluating corticosteroid (CS) dosing for patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) have largely excluded patients admitted directly to the intensive care unit (ICU), and none have evaluated the effect of CS dosing regimens on mortality. Objectives: To examine the effectiveness and safety of lower-versus high-dose CS in patients admitted to the ICU with an AECOPD. Methods: This pharmacoepidemiologic cohort study evaluated ICU patients with AECOPD admitted to one of 473 hospitals and treated with CS within the first 2 days between January 1, 2003 and December 31, 2008. Patients were grouped into lower-dose (methylprednisolone, <240 mg/d) or high-dose (methylprednisolone, .240 mg/d) groups based on CS dosage on hospital Day 1 or 2. The primary outcome was hospital mortality. Measurements and Main Results: A total of 17,239 patients were included; 6,156 (36%) were in the lower-dose and 11,083 (64%) in the high-dose CS group. After propensity score matching and adjustment for unbalanced covariates, lower-dose CS was not associated with a significant reduction in mortality (odds ratio, 0.85; 95% confidence interval [CI], 0.71-1.01; P = 0.06), but it was associated with reduced hospital (20.44 d; 95% CI, 20.67 to 20.21; P , 0.01) and ICU (20.31 d; 95% CI, 20.46 to 20.16; P , 0.01) length-of-stay, hospital costs (2$2,559; 95% CI, 2$4,508 to 2$609; P = 0.01), length of invasive ventilation (20.29 d; 95% CI, 20.52 to 20.06; P = 0.01), need for insulin therapy (22.7% vs. 25.1%; P , 0.01), and fungal infections (3.3% vs. 4.4%; P , 0.01). Conclusions: Two-thirds of patients admitted to the ICU with an AECOPD are treated with high doses of CS that are associated with worse outcomes and more frequent adverse effects. Lower dosage strategies should be encouraged for patients admitted to the ICU and the optimum dose should be determined through clinical trials.
The Open Critical Care Medicine Journal, 2010
Recently published consensus treatment guidelines for pediatric sepsis recommend initiating corticosteroid replacement therapy (CRT) for those critically ill children with adrenal insufficiency and refractory shock. The data to support this recommendation is limited, and multiple studies have demonstrated significant variation in both the diagnosis and treatment of adrenal insufficiency and refractory shock in children. In order to better define the variation in practice at our institution, we retrospectively reviewed the experience with CRT in critically ill children with refractory septic shock over a 1-year-period. In addition, as a secondary aim we compared outcomes in critically ill children treated with CRT for variable lengths of time. We found that the initiation of CRT at our center is relatively consistent. However, we noted significant variation in the duration of CRT and whether CRT was gradually tapered or stopped abruptly. The majority of the patients in our cohort received less than the currently recommended duration of 7 days of CRT. There were a higher number of treatment failures in those patients who received CRT for greater than 7 days, suggesting that CRT should be tapered gradually in these patients. There is significant variation in prescribing trends for CRT at our institution, which are likely to be compounded in any multi-center cohort study of CRT in critically ill children with septic shock. Practice variation in CRT should be standardized to address the impact of CRT in this population.
2013
Objective The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. Design Self-administered paper survey. Population Intensivists in academic hospitals with clinical trial expertise in critical illness. Measurements We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected Electronic supplementary material The online version of this article (
The Best Use of Systemic Corticosteroids in the Intensive Care Units, Review
Journal of Steroids & Hormonal Science, 2015
Corticosteroids are one of the most common medications that are used in the intensive care units (ICUs); corticosteroids are used for a variety of indications, including septic shock, acute respiratory distress syndrome (ARDS), bacterial meningitis, tuberculous meningitis, lupus nephritis, severe chronic obstructive pulmonary disease (COPD) exacerbations and many others.
Journal of the ASEAN Federation of Endocrine Societies, 2023
Objectives. Among critically ill patients, there is usually impairment of the hypothalamic-pituitary-adrenal axis, leading to a condition known as critical illness-related corticosteroid insufficiency (CIRCI). This investigation aims to determine the incidence of and characterize CIRCI among patients with COVID-19 as well as to analyze the outcomes of these critically ill patients. Methodology. This is a single-center, retrospective cohort study that investigated the occurrence of CIRCI among critically ill patients infected with COVID-19. Results. In this cohort, there were 145 COVID-19-positive patients with refractory shock, which reflects that 22.94% of the COVID-19 admissions have probable CIRCI. Patients who were given corticosteroids were found to have statistically significant longer median days on a ventilator (p=0.001). However, those on the corticosteroid arm were at higher risk of morbidity and mortality and a greater proportion had organ dysfunction. Multivariable logistic regression analysis revealed that SOFA score was a significant predictor of mortality in CIRCI (p=0.013). Conclusion. CIRCI has a unique presentation among patients with COVID-19 because of the presence of a high level of inflammation in this life-threatening infection. It is possibly a harbinger of a markedly increased risk of mortality in these patients.
Corticosteroids influence the mortality and morbidity of acute critical illness
Critical Care, 2006
Introduction Use of corticosteroids for adrenal supplementation and attenuation of the inflammatory and immune response is widespread in acute critical illness. The study hypothesis was that exposure to corticosteroids influences the mortality and morbidity in acute critical illness. Methods This case–control retrospective study was performed in a single multidisciplinary intensive care unit at a tertiary care institution and consisted of 10,285 critically ill patients admitted between 1 January 1999 and 31 December 2004. Demographics, comorbidities, acute illness characteristics including severity measured by Sequential Organ Failure Assessment, concurrent medications, therapeutic interventions and incidence of infections were obtained from electronic medical records, were examined with multiple regression analysis and were adjusted for propensity of corticosteroid exposure. The primary outcome was hospital death, and the secondary outcome was transfer to a care facility at hospital discharge. Results Corticosteroid exposure in 2,632 (26%) patients was characterized by younger age, more females, higher Charlson comorbidity and maximal daily Sequential Organ Failure Assessment scores compared with control patients. Corticosteroids potentiated metabolic and neuromuscular sequels of critical illness with increased requirements for diuretics, insulin, protracted weaning from mechanical ventilation, need for tracheostomy and discharge to a care facility. Early exposure to corticosteroids predisposed to recurrent and late onset of polymicrobial and fungal hospital-acquired infections. Corticosteroids increased the risk for death or disability after adjustments for comorbidities and acute illness characteristics. Conclusion Corticosteroids increased the risk for death or disability in critical illness. Hospital-acquired infections and metabolic and neuromuscular sequels of critical illness were exacerbated by corticosteroids. Careful appraisal of the indications for use of corticosteroids is necessary to balance the benefits and risks from exposure in acute critical illness.
Corticosteroid therapy and intercurrent illness: the need for continuing patient education
Postgraduate medical journal, 1993
In patients receiving long-term therapeutic or replacement corticosteroids, delayed or inappropriate adjustment of steroid dosage during intercurrent illness may be fatal. We used a questionnaire to assess current levels of patient knowledge, awareness of the need for action during intercurrent illness and the frequency with which steroid warning cards and Medic Alert pendants were carried, in 61 patients on long-term replacement corticosteroids and in 40 patients receiving long-term therapeutic corticosteroids. Only 67 of the 101 patients taking corticosteroids were carrying a steroid warning card. Eleven of the 21 Medic Alert owners wore their pendants. Only 18 of the 41 patients in the therapeutic group and 41 of the 60 patients in the replacement group would take appropriate action during an intercurrent illness (P < 0.001). Lack of patient knowledge in this important area emphasizes the need for continuing and effective education of these groups of patients during follow-up....