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Critical Illness Related Corticosteroid Insufficiency (CIRCI)

  • Akhil Khosla
  • Amy M. AhasicEmail author
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Abstract

Critical illness-related corticosteroid insufficiency (CIRCI) is a relative adrenal insufficiency in critically ill patients characterized by dysregulated systemic inflammation resulting in inadequate glucocorticoid activity for the severity of the patient’s illness (Annane et al., Crit Care Med. 45:2078–88, 2017). CIRCI may be secondary to dysregulation of the hypothalamic pituitary adrenal axis (HPA) and/or tissue resistance to glucocorticoids. CIRCI is associated with a broad spectrum of critical illness such as septic shock, community acquired pneumonia (CAP), cardiopulmonary bypass surgery, cardiac arrest, and trauma. CIRCI should be suspected when patients with such illnesses have refractory hypotension that fails to respond to conventional therapies. Patients with CIRCI may benefit from corticosteroids, but the evidence is conflicting, and routine cortisol measurement or ACTH stimulation testing in patients admitted to the intensive care unit is not recommended.

Keywords

Adrenal insufficiency Critical illness-related corticosteroid insufficiency (CIRCI) Relative adrenal insufficiency Steroid replacement ACTH stimulation testing, refractory shock 

References

  1. 1.
    Annane D, Pastores SM, Rochwerg B, et al. 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. Crit Care Med. 2017;45(12):2078–88.CrossRefGoogle Scholar
  2. 2.
    Asare K. Diagnosis and treatment of adrenal insufficiency in the critically ill patient. Pharmacotherapy. 2007;27(11):1512–28.CrossRefGoogle Scholar
  3. 3.
    Marik PE. Critical illness-related corticosteroid insufficiency. Chest. 2009;135(1):181–93.CrossRefGoogle Scholar
  4. 4.
    Annane D, Maxime V, Ibrahim F, Alvarez JC, Abe E, Boudou P. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med. 2006;174(12):1319–26.CrossRefGoogle Scholar
  5. 5.
    Pastores SM, Annane D, Rochwerg B, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med. 2018;46(1):146–8.CrossRefGoogle Scholar
  6. 6.
    Marik PE, Pastores SM, Annane D, Meduri GU, Sprung CL, Arlt W, et al. 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. Crit Care Med. 2008;36(6):1937–49.CrossRefGoogle Scholar
  7. 7.
    Marik PE, Zaloga GP. Adrenal insufficiency in the critically ill: a new look at an old problem. Chest. 2002;122(5):1784–96.CrossRefGoogle Scholar
  8. 8.
    Marik PE. The diagnosis of adrenal insufficiency in the critically ill patient: does it really matter? Crit Care. 2006;10(6):176.CrossRefGoogle Scholar
  9. 9.
    Marik PE. Mechanisms and clinical consequences of critical illness associated adrenal insufficiency. Curr Opin Crit Care. 2007;13(4):363–9.CrossRefGoogle Scholar
  10. 10.
    Marik PE, Gayowski T, Starzl TE, Group HCRaAPS. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33(6):1254–9.CrossRefGoogle Scholar
  11. 11.
    Hamrahian A. Adrenal function in critically ill patients: how to test? When to treat? Cleve Clin J Med. 2005;72(5):427–32.CrossRefGoogle Scholar
  12. 12.
    Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004;350:1629–38.CrossRefGoogle Scholar
  13. 13.
    Jessop DS, Turner-Cobb JM. Measurement and meaning of salivary cortisol: a focus on health and disease in children. Stress. 2008;11:1–14.CrossRefGoogle Scholar
  14. 14.
    Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med. 2003;348(8):727–34.CrossRefGoogle Scholar
  15. 15.
    Lipiner-Friedman D, Sprung CL, Laterre PF, Weiss Y, Goodman SV, Vogeser M, et al. Adrenal function in sepsis: the retrospective Corticus cohort study. Crit Care Med. 2007;35(4):1012–8.CrossRefGoogle Scholar
  16. 16.
    Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003;361(9372):1881–93.CrossRefGoogle Scholar
  17. 17.
    Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637.CrossRefGoogle Scholar
  18. 18.
    Venkatesh B, et al. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378(9):797–808.CrossRefGoogle Scholar
  19. 19.
    Annane D, et al. Hydrocortisfone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018;378:809–18.CrossRefGoogle Scholar
  20. 20.
    Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2016. Crit Care Med. 2017;45(3):486–552.CrossRefGoogle Scholar
  21. 21.
    Sligl WI, Milner DA, Sundar S, Mphatswe W, Majumdar SR. Safety and efficacy of corticosteroids for the treatment of septic shock: a systematic review and meta-analysis. Clin Infect Dis. 2009;49(1):93–101.CrossRefGoogle Scholar
  22. 22.
    Annane D, Bellissant E, Bollaert PE, Briegel J, Confalonieri M, De Gaudio R, et al. Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA. 2009;301(22):2362–75.CrossRefGoogle Scholar
  23. 23.
    Minneci PC, Deans KJ, Natanson C. Corticosteroid therapy for severe sepsis and septic shock. JAMA. 2009;302(15):1643; author reply 4–5CrossRefGoogle Scholar
  24. 24.
    Minneci PC, Deans KJ, Eichacker PQ, Natanson C. The effects of steroids during sepsis depend on dose and severity of illness: an updated meta-analysis. Clin Microbiol Infect. 2009;15(4):308–18.CrossRefGoogle Scholar
  25. 25.
    Moran JL, Graham PL, Rockliff S, Bersten AD. Updating the evidence for the role of corticosteroids in severe sepsis and septic shock: a Bayesian meta-analytic perspective. Crit Care. 2010;14(4):R134.CrossRefGoogle Scholar
  26. 26.
    Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862–71.CrossRefGoogle Scholar
  27. 27.
    Martínez R, Menéndez R, Reyes S, et al. Factors associated with inflammatory cytokine patterns in community-acquired pneumonia. Eur Respir J. 2011;37:393–9.CrossRefGoogle Scholar
  28. 28.
    Pene F, Hyvernat H, Mallet V, et al. Prognostic value of relative adrenal insufficiency after out-of-hospital cardiac arrest. Intensive Care Med. 2005;31:627–33.CrossRefGoogle Scholar
  29. 29.
    Paris PM, Stewart RD, Deggler F. Prehospital use of dexamethasone in pulseless idioventricular rhythm. Ann Emerg Med. 1984;13:1008–10.CrossRefGoogle Scholar
  30. 30.
    Tsai MS, Huang CH, Chang WT, et al. The effect of hydrocortisone on the outcome of out-of-hospital cardiac arrest patients: a pilot study. Am J Emerg Med. 2007;25:318–25.CrossRefGoogle Scholar
  31. 31.
    Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med. 2009;169:15–24.CrossRefGoogle Scholar
  32. 32.
    Paparella D, Yau TM, Young E. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg. 2002;21:232–44.CrossRefGoogle Scholar
  33. 33.
    Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111–24.CrossRefGoogle Scholar
  34. 34.
    Walls RM, Murphy MF. Clinical controversies: etomidate as an induction agent for endotracheal intubation in patients with sepsis: continue to use etomidate for intubation of patients with septic shock. Ann Emerg Med. 2008;52(1):13–4.CrossRefGoogle Scholar
  35. 35.
    Policola C, Stokes V, Karavitaki N, Grossman A. Adrenal insufficiency in acute oral opiate therapy. Endocrinol Diabetes Metab Case Rep. 2014;2014:130071.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Schimke KE, Greminger P, Brändle M. Secondary adrenal insufficiency due to opiate therapy—another differential diagnosis worth consideration. Exp Clin Endocrinol Diabetes. 2009;117(10):649–51.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Section of Pulmonary, Critical Care and Sleep MedicineYale University School of MedicineNew HavenUSA
  2. 2.Section of Pulmonary, Critical Care and Sleep MedicineNorwalk Hospital, Nuvance HealthNorwalkUSA

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