Chest
Recent Advances in Chest MedicineCritical Illness-Related Corticosteroid Insufficiency
Section snippets
Cortisol Physiology
Cortisol (hydrocortisone) is the major endogenous glucocorticoid secreted by the adrenal cortex. Over 90% of circulating cortisol is bound to corticosteroid-binding globulin (CBG) with < 10% in the free, biologically active form.5, 6 CBG is the predominant binding protein with albumin binding a lesser amount. During acute illness, particularly sepsis, CBG levels fall by as much as 50%, resulting in a significant increase in the percentage of free cortisol.7, 8 The circulating half-life of
Critical Illness-Related Corticosteroid Insufficiency
There has recently been a great deal of interest regarding the assessment of adrenal function and the indications for corticosteroid therapy in critically ill patients. While the use of high-dose corticosteroid (10,000 to 40,000 mg of hydrocortisone equivalent in > 24 h) in patients with severe sepsis and ARDS failed to improve outcome and was associated with increased complications,28, 29 an extended course of stress-dose corticosteroids (200 to 350 mg hydrocortisone equivalent per day for up
Clinical Manifestations of CIRCI
Patients with chronic adrenal insufficiency (Addison Disease) usually present with a history of weakness, weight loss, anorexia, and lethargy with some patients complaining of nausea, vomiting, abdominal pain, and diarrhea. Clinical signs include orthostatic hypotension and hyperpigmentation (primary adrenal insufficiency). Laboratory testing may demonstrate hyponatremia, hyperkalemia, hypoglycemia, and a normocytic anemia. This presentation contrasts with the features of CIRCI. The clinical
Diagnosis of Adrenal Insufficiency and CIRCI
Traditionally the diagnosis of adrenal insufficiency in the critically ill has been based on the measurement of a random total serum cortisol (stress cortisol level) or the change in the serum cortisol in response to 250 ug of synthetic ACTH (cosyntropin), the so called delta cortisol.60, 61 Both of these tests have significant limitations in the critically ill.62 Commercially available cortisol assays measure the total hormone concentration rather than the biologically active, free cortisol
Treatment With Corticosteroids: Who and How?
Over the last three decades, approximately 20 randomized controlled trials (RCTs) have been conducted evaluating the role of glucocorticoids in patients with sepsis, severe sepsis, septic shock, and ARDS. Varying doses (37.5 to 40,000 mg of hydrocortisone eq/day), dosing strategies (eg, single bolus, repeat boluses, continuous infusion, and dose taper) and duration of therapy (1 to 32 days) were used in these studies.28, 29 The results of these studies together with our current understanding of
Conclusion
Critical illness-related corticosteroid insufficiency (CIRCI) is a complex disease, and our understanding of this disease continues to evolve. In critically ill patients with catecholamine refractory septic shock and patients with persistent severe ARDS for > 48 h after supportive therapy, a course of stress-dose corticosteroids (200 to 350 mg/d of hydrocortisone or 40 to 70 mg/d of methylprednisolone) should be considered. Treatment for at least 7 days (and up to 14 days) is suggested,
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