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Goder N, Gerstenhaber F, Gal Oz A, Stavi D, Angel Y, Nini A, Lichter Y, Sold O. Cortisol Levels During First Admission Day Are Associated With Clinical Outcomes in Surgical Critically Ill Patients. Crit Care Explor 2024; 6:e1086. [PMID: 38722303 PMCID: PMC11081545 DOI: 10.1097/cce.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
IMPORTANCE To explore the correlation between cortisol levels during first admission day and clinical outcomes. OBJECTIVES Although most patients exhibit a surge in cortisol levels in response to stress, some suffer from critical illness-related corticosteroid insufficiency (CIRCI). Literature remains inconclusive as to which of these patients are at greater risk of poor outcomes. DESIGN A retrospective study. SETTING A surgical ICU (SICU) in a tertiary medical center. PARTICIPANTS Critically ill patients admitted to the SICU who were not treated with steroids. MAIN OUTCOMES AND MEASURES Levels of cortisol taken within 24 hours of admission (day 1 [D1] cortisol) in 1412 eligible patients were collected and analyzed. Results were categorized into four groups: low (0-10 µg/dL), normal (10-25 µg/dL), high (25-50 µg/dL), and very high (above 50 µg/dL) cortisol levels. Primary endpoint was 90-day mortality. Secondary endpoints were the need for organ support (use of vasopressors and mechanical ventilation [MV]), ICU length of stay (LOS), and duration of MV. RESULTS The majority of patients (63%) had high or very high D1 cortisol levels, whereas 7.6% had low levels and thus could be diagnosed with CIRCI. There were statistically significant differences in 90-day mortality between the four groups and very high levels were found to be an independent risk factor for mortality, primarily in patients with Sequential Organ Failure Assessment (SOFA) less than or equal to 3 or SOFA greater than or equal to 7. Higher cortisol levels were associated with all secondary endpoints. CIRCI was associated with favorable outcomes. CONCLUSIONS AND RELEVANCE In critically ill surgical patients D1 cortisol levels above 50 mcg/dL were associated with mortality, need for organ support, longer ICU LOS, and duration of MV, whereas low levels correlated with good clinical outcomes even though untreated. D1 cortisol level greater than 50 mcg/dL can help discriminate nonsurvivors from survivors when SOFA less than or equal to 3 or SOFA greater than or equal to 7.
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Affiliation(s)
- Noam Goder
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fabian Gerstenhaber
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Gal Oz
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dekel Stavi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Angel
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaph Nini
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lichter
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sold
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abdelrehim AB, Mohsen FM, Haredi MA, Abdel Hameed Z, Ibrahim WH. PROGNOSTIC VALUE OF LOW-DOSE ADRENOCORTICOTROPIC HORMONE TEST IN CRITICALLY ILL PATIENTS. Shock 2023; 59:871-876. [PMID: 37011042 DOI: 10.1097/shk.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
ABSTRACT Background: Previous trials evaluated the incidence of critical illness-related corticosteroid insufficiency (CIRCI) using 250 μg adrenocorticotropic hormone (ACTH). However, this supraphysiological dose could result in false-positive levels. We aimed to determine the incidence of CIRCI in septic patients using a 1 μg ACTH stress test. Methods: We conducted a prospective cohort study on 39 patients with septic shock. Critical illness-related corticosteroid insufficiency was defined as a Δ max cortisol <9 μg/dL after 1 μg ACTH stress test. The primary outcome of the study was death. Secondary outcomes included days of vasopressors, days of mechanical ventilation (MV), amount of fluid per day, the incidence of acute kidney injury (AKI), and days of intensive care unit (ICU) stay. Results: The incidence of CIRCI in our cohort was 43.6% using 1 μg ACTH. There were no significant differences between groups in terms of ICU scores, laboratory investigations, vasopressors, MV days, amount of fluid per day, and the ICU stay ( P = > 0.05). The CIRCI group had lower median survival and survival probability rates (5 days and 48.4%, respectively) compared with the non-CIRCI group (7 days and 49.5%, respectively). In addition, the CIRCI group had a shorter time to develop AKI and a higher probability of developing AKI (4 days and 44.6%, respectively) in comparison with the non-CIRCI group (6 days and 45.57%, respectively). Conclusion: We concluded that the CIRCI group had a lower mean survival rate and a higher incidence of AKI. We recommend the use of 1 μg ACTH test in septic shock patients to identify this subgroup of patients.
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Affiliation(s)
| | - Fatma M Mohsen
- Department of Internal Medicine, Critical Care Unit, Assiut University Hospital, Egypt
| | - Mostafa A Haredi
- Department of Internal Medicine, Endocrinology Unit, Assiut University Hospital, Egypt
| | | | - Walaa Hosny Ibrahim
- Department of Internal Medicine, Nephrology Unit, Assiut University Hospital, Egypt
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Muacevic A, Adler JR, Tsikrika A, Tsolaki V. Life-Threatening Hypotension in a Brain-Injured, Multi-Trauma Patient With Unilateral Adrenal Gland Damage: How a Single Hydrocortisone Dose Revealed Relative Corticosteroid Insufficiency. Cureus 2022; 14:e32843. [PMID: 36694505 PMCID: PMC9867564 DOI: 10.7759/cureus.32843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
We report a case of a multi-trauma, brain-injured young patient with unilateral adrenal gland injury presenting with refractory shock. Acute adrenal insufficiency was revealed after an abrupt hemodynamic response to a corticosteroid; the resistant shock was quickly resolved with IV hydrocortisone. Although available data do not support the use of empiric steroids in trauma patients (with or without brain injury), this case demonstrates that adrenal insufficiency must be considered in the differential diagnosis when shock exists; adrenal gland injury, even unilateral, may play an additional factor. In these cases, an urgent decision is required in order to influence the outcome.
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Huang CS, Miles T, Thomas B, Todd SR, Wilson CT, Suliburk J. A call for standardization: Practice patterns and management of critical illness-related corticosteroid insufficiency in surgical intensive care units. Injury 2021; 52:2522-2525. [PMID: 34158159 DOI: 10.1016/j.injury.2021.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/02/2021] [Accepted: 05/21/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Critical illness-rlated corticosteroid insufficiency (CIRCI) is a known sequela of severe injury and illness, yet its diagnosis and management are challenging. We hypothesized that CIRCI has significant variability in its diagnosis and management within surgical intensive care units (SICUs). Our study aimed to assess the state of practice of CIRCI in the American College of Surgery Committee on Trauma (ACS COT) certified level 1 trauma centers. METHODS An 11-item questionnaire was developed based on a CIRCI literature search with expert input from medical endocrinology, acute care surgeons, and surgical intensivists to assess practice patterns of CIRCI. Prior to distribution, it was validated across 2 separate institutions by board-certified critical care surgeons. The questionnaire was distributed to trauma intensivists within level 1 trauma centers in Southeast United States and was open from April 2019 to January 2020. RESULTS A total of 56 responses were collected with a response rate of 70%. 72% of respondents indicated they evaluate or manage CIRCI on a weekly basis. In regards to the diagnosis of CIRCI, only 5% of respondents use a formal protocol and 32% do not use laboratory testing. While a majority of respondents (94%) use corticosteroids in septic shock, 67% of those surveyed have not implemented mineralocorticoids as part of the management. 83% of respondents indicated a knowledge gap exists in the therapeutic value of corticosteroids for hemorrhagic shock. CONCLUSIONS This study demonstrates extreme variability in the diagnosis and management of CIRCI. In particular most providers acknowledge a knowledge gap in the diagnosis of CIRCI and the role of corticosteroids in hemorrhagic shock. Few providers are using adjunctive mineralocorticoids in septic shock, although recent level 1 evidence have shown a survival benefit. These responses reflect an opportunity for national improvement in the management of CIRCI.
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Affiliation(s)
| | - Travis Miles
- Baylor College of Medicine, Houston TX, 77030, USA.
| | - Brice Thomas
- Baylor College of Medicine, Houston TX, 77030, USA.
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Yozova ID, Sano H, Weidgraaf K, Candy EJ, Cockrem JF. A randomized cross-over trial assessing salivary and urinary cortisol concentrations after alfaxalone and propofol administration in healthy cats. Domest Anim Endocrinol 2021; 74:106557. [PMID: 33039929 DOI: 10.1016/j.domaniend.2020.106557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 11/18/2022]
Abstract
The aim of this study was to assess the effects of commonly used anaesthetics alfaxalone and propofol on salivary and urinary cortisol in healthy cats. Fifteen male castrated research-purposed cats received randomly intravenous continuous rate infusions of 8 mg/kg/h of alfaxalone, 12 mg/kg/h of propofol and 2 ml/kg/h of Lactated Ringer's solution for 30 min, with intervals of 6 days between treatments. Saliva samples were collected for 24 h before each infusion and for 24 h from the start of each infusion. Urine was collected as single pooled samples over each 24 h period. Mean integrated saliva cortisol responses in cats treated with alfaxalone were greater than responses of cats treated with propofol (P = 0.034) and controls (P = 0.017). Integrated responses in cats treated with propofol did not differ from controls. The mean urinary cortisol/creatinine ratio (UCCR) was higher on the day of treatment than the day before treatment in cats treated with alfaxalone (P < 0.0001) and in cats treated with propofol (P = 0.0168) and did not differ between days in cats treated with lactated Ringer's solution. The mean UCCR was higher in cats treated with alfaxalone than in cats treated with lactated Ringer's solution (P = 0.0020) on the day of treatment. Mean total urinary cortisol over 24 h was greater in cats treated with alfaxalone than controls (P = 0.0267). In conclusion, alfaxalone increased short-term salivary and urinary cortisol concentrations in healthy cats as compared to propofol and a control group of non-anesthetised cats.
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Affiliation(s)
- I D Yozova
- Massey University Pet Emergency Centre, School of Veterinary Science, Massey University, Palmerston North, New Zealand.
| | - H Sano
- Department of Anaesthesia and Analgesia, School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - K Weidgraaf
- The Centre for Feline Nutrition, Massey University, New Zealand
| | - E J Candy
- Endocrinology Laboratory, School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - J F Cockrem
- Endocrinology Laboratory, School of Veterinary Science, Massey University, Palmerston North, New Zealand
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Hoareau GL, Williams TK, Davidson AJ, Russo RM, Ferencz SAE, Neff LP, Grayson JK, Stewart IJ, Johnson MA. Endocrine Effects of Simulated Complete and Partial Aortic Occlusion in a Swine Model of Hemorrhagic Shock. Mil Med 2020; 184:e298-e302. [PMID: 30371879 DOI: 10.1093/milmed/usy287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/24/2018] [Accepted: 10/06/2018] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Low distal aortic flow via partial aortic occlusion (AO) may mitigate ischemia induced by resuscitative endovascular balloon occlusion of the aorta (REBOA). We compared endocrine effects of a novel simulated partial AO strategy, endovascular variable aortic control (EVAC), with simulated REBOA in a swine model. MATERIALS AND METHODS Aortic flow in 20 swine was routed from the supraceliac aorta through an automated extracorporeal circuit. Following liver injury-induced hemorrhagic shock, animals were randomized to control (unregulated distal flow), simulated REBOA (no flow, complete AO), or simulated EVAC (distal flow of 100-300 mL/min after 20 minutes of complete AO). After 90 minutes, damage control surgery, resuscitation, and full flow restoration ensued. Critical care was continued for 4.5 hours or until death. RESULTS Serum angiotensin II concentration was higher in the simulated EVAC (4,769 ± 624 pg/mL) than the simulated REBOA group (2649 ± 429) (p = 0.01) at 180 minutes. There was no detectable difference in serum renin [simulated REBOA: 231.3 (227.9-261.4) pg/mL; simulated EVAC: 294.1 (231.2-390.7) pg/mL; p = 0.27], aldosterone [simulated EVAC: 629 (454-1098), simulated REBOA: 777 (575-1079) pg/mL, p = 0.53], or cortisol (simulated EVAC: 141 ± 12, simulated REBOA: 127 ± 9 ng/mL, p = 0.34) concentrations between groups. CONCLUSIONS Simulated EVAC was associated with higher serum angiotensin II, which may have contributed to previously reported cardiovascular benefits. Future studies should evaluate the renal effects of EVAC and the concomitant therapeutic use of angiotensin II.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA
| | - Timothy K Williams
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, 1 Medical Center Blvd, Winston-Salem, NC
| | - Anders J Davidson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | - Rachel M Russo
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | | | - Lucas P Neff
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
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Chen X, Chai Y, Wang SB, Wang JC, Yue SY, Jiang RC, Zhang JN. Risk factors for corticosteroid insufficiency during the sub-acute phase of acute traumatic brain injury. Neural Regen Res 2020; 15:1259-1265. [PMID: 31960811 PMCID: PMC7047797 DOI: 10.4103/1673-5374.272611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Hypothalamic-pituitary-adrenal axis dysfunction may lead to the occurrence of critical illness-related corticosteroid insufficiency. Critical illness-related corticosteroid insufficiency can easily occur after traumatic brain injury, but few studies have examined this occurrence. A multicenter, prospective, cohort study was performed to evaluate the function of the hypothalamic-pituitary-adrenal axis and the incidence of critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. One hundred and forty patients with acute traumatic brain injury were enrolled from the neurosurgical departments of three tertiary-level hospitals in China, and the critical illness-related corticosteroid insufficiency incidence, critical-illness-related corticosteroid insufficiency-related risk factors, complications, and 28-day mortality among these patients was recorded. Critical illness-related corticosteroid insufficiency was diagnosed in patients with plasma total cortisol levels less than 10 μg/dL (275.9 nM) on post-injury day 4 or when serum cortisol was insufficiently suppressed (less than 50%) during a dexamethasone suppression test on post-injury day 5. The results demonstrated that critical illness-related corticosteroid insufficiency occurred during the sub-acute phase of traumatic brain injury in 5.6% of patients with mild injury, 22.5% of patients with moderate injury, and 52.2% of patients with severe injury. Traumatic brain injury-induced critical illness-related corticosteroid insufficiency was strongly correlated to injury severity during the sub-acute stage of traumatic brain injury. Traumatic brain injury patients with critical illness-related corticosteroid insufficiency frequently presented with hemorrhagic cerebral contusions, diffuse axonal injury, brain herniation, and hypotension. Differences in the incidence of hospital-acquired pneumonia, gastrointestinal bleeding, and 28-day mortality were observed between patients with and without critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. Hypotension, brain-injury severity, and the types of traumatic brain injury were independent risk factors for traumatic brain injury-induced critical illness-related corticosteroid insufficiency. These findings indicate that critical illness-related corticosteroid insufficiency is common during the sub-acute phase of traumatic brain injury and is strongly associated with poor prognosis. The dexamethasone suppression test is a practical assay for the evaluation of hypothalamic-pituitary-adrenal axis function and for the diagnosis of critical illness-related corticosteroid insufficiency in patients with traumatic brain injury, especially those with hypotension, hemorrhagic cerebral contusions, diffuse axonal injury, and brain herniation. Sub-acute infection of acute traumatic brain injury may be an important factor associated with the occurrence and development of critical illness-related corticosteroid insufficiency. This study protocol was approved by the Ethics Committee of General Hospital of Tianjin Medical University, China in December 2011 (approval No. 201189).
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Affiliation(s)
- Xin Chen
- Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yan Chai
- Tianjin Neurological Institute; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Shao-Bo Wang
- Department of Neurosurgery, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region, China
| | - Jia-Chong Wang
- Department of Neurosurgery, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Changsha, Hunan Province, China
| | - Shu-Yuan Yue
- Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Rong-Cai Jiang
- Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Jian-Ning Zhang
- Tianjin Neurological Institute; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
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Digiacomo JC, Gerber N, Angus LDG, Munnangi S, Cardozo-Stolberg S. Blunt Adrenal Injury: Results of a State Trauma Registry Review. Am Surg 2019. [DOI: 10.1177/000313481908500430] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the past, injuries to the adrenal glands due to blunt trauma were considered rare, and were reported to be associated with high Injury Severity Scores (ISSs) and high mortality. Recent reports have reported a much high incidence associated with lower ISS and lower mortality. The purpose of this study was to assess the incidence of adrenal gland injuries due to blunt trauma in a large state trauma registry and determine whether these injuries are associated with a higher ISS and increased risk for mortality. A retrospective review was performed on the New York State Trauma Registry comparing blunt injured adults with adrenal injuries to those who did not. Concurrent organ injuries, ISS, and inhospital mortality were compared. Three hundred thirty-nine patients with adrenal gland injuries were identified. Concurrent liver and kidney injuries were more prevalent in the adrenal injured group, and concurrent injuries to the small and large intestine and spleen were more prevalent in the nonadrenal injured group. There was no difference in ISS or mortality between the adrenal injured and nonadrenal injured populations. The results of this study are consistent with recent smaller studies which identified incidence rates which were higher than previously reported and that ISS and mortality risk were unchanged by the presence of blunt adrenal gland injuries. Adrenal gland injuries due to blunt trauma are not uncommon, with an incidence rate of 0.61 per cent. Adrenal gland injuries are not associated with higher ISS or an increased risk of mortality.
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Affiliation(s)
- Jody C. Digiacomo
- Department of Surgery, Nassau University Medical Center, East Meadow, New York
| | - Noam Gerber
- Department of Surgery, Nassau University Medical Center, East Meadow, New York
| | - L. D. George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, New York
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, New York
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Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I). Crit Care Med 2017; 45:2078-2088. [DOI: 10.1097/ccm.0000000000002737] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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10
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Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A, Briegel J, Carcillo J, Christ-Crain M, Cooper MS, Marik PE, Umberto Meduri G, Olsen KM, Rodgers S, Russell JA, Van den Berghe G. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med 2017; 43:1751-1763. [PMID: 28940011 DOI: 10.1007/s00134-017-4919-5] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/19/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. PARTICIPANTS 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. DESIGN/METHODS 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 the evidence. Recommendation approval required the agreement of at least 80% of the task force members. RESULTS The task force was unable to reach agreement on a single test that 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. We suggest against using plasma free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using intravenous (IV) hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence). CONCLUSIONS Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.
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Affiliation(s)
- Djillali Annane
- General ICU Department, Raymond Poincaré Hospital (APHP), Helath Science Centre Simone Veil, Universite Versailles SQY-Paris Saclay, Garches, France.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-1179, New York, NY, 10065, USA.
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wiebke Arlt
- Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Institute of Metabolism and Systems Research (IMSR), University of Birmingham and Centre for Endocrinology, Birmingham, UK
| | - Robert A Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Josef Briegel
- Anesthesiology and Critical Care Medicine, Klinik für Anästhesiologie, Klinikum der Universität, Munich, Germany
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Mark S Cooper
- Department of Endocrinology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Gianfranco Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Keith M Olsen
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sophia Rodgers
- Clinical Adjunct Faculty, University of New Mexico and Sandoval Regional Medical Center, Albuquerque, NM, USA
| | - James A Russell
- Division of Critical Care Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University and Hospitals, Louvain, 3000, Belgium
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11
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Pisano SRR, Howard J, Posthaus H, Kovacevic A, Yozova ID. Hydrocortisone therapy in a cat with vasopressor-refractory septic shock and suspected critical illness-related corticosteroid insufficiency. Clin Case Rep 2017; 5:1123-1129. [PMID: 28680609 PMCID: PMC5494402 DOI: 10.1002/ccr3.1018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/05/2017] [Accepted: 05/01/2017] [Indexed: 01/22/2023] Open
Abstract
A 27‐month‐old female cat was presented with septic peritonitis secondary to a ruptured pyometra and subsequent pyothorax. Vasopressor‐refractory septic shock led to a suspicion of critical illness‐related corticosteroid insufficiency, successfully treated with intravenous hydrocortisone. Previous megestrol acetate administration may have played a role in the development of adrenocortical dysfunction.
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Affiliation(s)
- Simone R R Pisano
- Department of Clinical Veterinary Medicine Vetsuisse Faculty University of Bern Bern Switzerland
| | - Judith Howard
- Department of Clinical Veterinary Medicine Vetsuisse Faculty University of Bern Bern Switzerland
| | - Horst Posthaus
- Department of Infectious Diseases and Pathobiology Vetsuisse Faculty University of Bern Bern Switzerland
| | - Alan Kovacevic
- Department of Clinical Veterinary Medicine Vetsuisse Faculty University of Bern Bern Switzerland
| | - Ivayla D Yozova
- Institute of Veterinary, Animal and Biomedical Sciences Massey University Palmerston North New Zealand
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