Critical Illness-Related Corticosteroid Insufficiency

Background

• Critical illness-related corticosteroid insufficiency (CIRCI) is a syndrome characterized by an inadequate corticosteroid response for the severity of the current illness affecting the patient.
• It has been reported in 10%-20% of critically ill patients.
• Risk factors include severe sepsis, acute respiratory distress syndrome, medications that can suppress production of corticosteroids (such as etomidate, megestrol acetate, or ketoconazole), and conditions causing acute adrenal hemorrhage or infarction.

Evaluation

• Suspect CIRCI in patients in the intensive care unit (ICU) with hypotension poorly responsive to fluids and vasopressor support.
• Given the limitations of testing, current recommendations are for consideration of corticosteroid treatment based on clinical criteria rather than results of adrenal function testing (Weak recommendation).
• Consider a diagnosis of CIRCI in critically ill patients when either (Weak recommendation):
  • a random total serum cortisol is < 10 mcg/dL, or
  • there is an adrenal corticotropin hormone (ACTH) stimulation test (delta cortisol test) with a < 9 mcg/dL change in serum cortisol in response to 250 mcg synthetic ACTH (cosyntropin)

Management

• Consider corticosteroid treatment regardless of cortisol testing results in patients suspected of having CIRCI (Weak recommendation), including:
  • septic shock, especially if the shock is poorly responsive to fluid resuscitation and vasopressors
  • early moderate-to-severe acute respiratory distress syndrome (ARDS) with ratio of partial pressure of oxygen in arterial blood to fraction of inspired oxygen (PaO₂/FiO₂) < 200 and within 14 days
• The optimal treatment regimen for different causes has not been established. Options for treatment include:
  • for septic shock not responsive to vasopressor therapy and fluid resuscitation, low dose and long course (IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose)
  • for early severe ARDS, methylprednisolone 1 mg/kg/day IV for ≥ 7 days (up to 14 days)
  • for persistent severe ARDS, methylprednisolone 2 mg/kg/day IV for ≥ 7 days (up to 14 days)
• Complications of corticosteroid treatment include an increased risk of infection, poor wound healing, fluid retention, hyperglycemia, and psychosis.
• Taper the dose of corticosteroids when vasopressors are no longer required. Stopping corticosteroids abruptly may result in the recurrence of shock.