Log in | Register

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

Djillali Annane| Stephen M. Pastores| Bram Rochwerg| Wiebke Arlt| Robert A. Balk| Albertus Beishuizen| Josef Briegel| Joseph Carcillo| Mirjam Christ-Crain| Mark S. Cooper| Paul E. Marik| Gianfranco Umberto Meduri| Keith M. Olsen| Sophia Rodgers| James A. Russell| Greet Van den Berghe
Conference Reports and Expert Panel
Volume 43, Issue 12 / December , 2017

Pages 1751 - 1763

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.

Keywords

References

  1. Marik PE, Pastores SM, Annane D, Meduri GU, Sprung CL, Arlt W, Keh D, Briegel J, Beishuizen A, Dimopoulou I, Tsagarakis S, Singer M, Chrousos GP, Zaloga G, Bokhari F, Vogeser M, American College of Critical Care Medicine (2008) 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 36(6):1937–1949
    • View reference on publisher's website
    • View reference on PubMed
  2. Cochrane Collaboration (2012) Cochrane: review manager. Edition 5.2. Edited by Centre TNC. Cochrane Collaboration, Copenhagen
  3. Shea BJ, Grimshaw JM, Wells GA et al (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7:10
    • View reference on publisher's website
    • View reference on PubMed
  4. Higgins JP, Altman DG, Gøtzsche PC, Cochrane Bias Methods Group; Cochrane Statistical Methods Group et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928
    • View reference on publisher's website
    • View reference on PubMed
  5. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwel P (2016) The Newcastle--Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 21 Nov 2016
  6. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25
    • View reference on publisher's website
    • View reference on PubMed
  7. Kavanagh BP (2009) The GRADE system for rating clinical guidelines. PLoS Med 6(9):e1000094
    • View reference on publisher's website
    • View reference on PubMed
  8. Andrews JC, Schunemann HJ, Oxman AD et al (2013) GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol 66(7):726–735
    • View reference on publisher's website
    • View reference on PubMed
  9. Rhodes A, Evans LE, Alhazzani W et al (2016) Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Intensive Care Med 43(3):304–377
  10. Bornstein SR, Allolio B, Arlt W et al (2016) Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 101(2):364–389
    • View reference on publisher's website
    • View reference on PubMed
  11. Marik PE, Zaloga GP (2003) Adrenal insufficiency during septic shock. Crit Care Med 31(1):141–145
    • View reference on publisher's website
    • View reference on PubMed
  12. de Jong MF, Molenaar N, Beishuizen A, Groeneveld AB (2015) Diminished adrenal sensitivity to endogenous and exogenous adrenocorticotropic hormone in critical illness: a prospective cohort study. Crit Care 19:1. Erratum in: Crit Care. 2015;19:313
  13. Yang Y, Liu L, Jiang D, Wang J, Ye Z, Ye J, Chao J, Zhao M, Ao D, Qiu H (2014) Critical illness-related corticosteroid insufficiency after multiple traumas: a multicenter, prospective cohort study. J Trauma Acute Care Surg 76(6):1390–1396
    • View reference on publisher's website
    • View reference on PubMed
  14. Menon K, Ward RE, Lawson ML, Gaboury I, Hutchison JS, Hebert PC, Canadian Critical Care Trials Group (2010) A prospective multicenter study of adrenal function in critically ill children. Am J Respir Crit Care Med 182(2):246–251
    • View reference on publisher's website
    • View reference on PubMed
  15. Hamrahian AH, Oseni TS, Arafah BM (2004) Measurements of serum free cortisol in critically ill patients. N Engl J Med 350:1629–1638
    • View reference on publisher's website
    • View reference on PubMed
  16. Molenaar N, Groeneveld ABJ, Dijstelbloem HM et al (2011) Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness. Intensive Care Med 37:1986–1993
  17. Tarjanyi Z, Montsko G, Kenyeres P et al (2014) Free and total cortisol levels are useful prognostic markers in critically ill patients: a prospective observational study. Eur J Endocrinol 171:751–759
    • View reference on publisher's website
    • View reference on PubMed
  18. Jessop DS, Turner-Cobb JM (2008) Measurement and meaning of salivary cortisol: a focus on health and disease in children. Stress 11(1):1–14
    • View reference on publisher's website
    • View reference on PubMed
  19. Galbois A, Obadia E, Chalumeau-Lemoine L, Chelha R (2016) Using serum total cortisol assays overstates the adrenal insufficiency prevalence in cirrhotic patients. Eur Rev Med Pharmacol Sci 20(18):3730–3731
    • View reference on PubMed
  20. Galbois A, Rudler M, Massard J et al (2010) Assessment of adrenal function in cirrhotic patients: salivary cortisol should be preferred. J Hepatol 52(6):839–845
    • View reference on publisher's website
    • View reference on PubMed
  21. Estrada-Y-Martin RM, Orlander PR (2011) Salivary cortisol can replace free serum cortisol measurements in patients with septic shock. Chest 140(5):1216–1222
    • View reference on publisher's website
    • View reference on PubMed
  22. Coolens JL, Van Baelen H, Heyns W (1987) Clinical use of unbound plasma cortisol as calculated from total cortisol and corticosteroid-binding globulin. J Steroid Biochem 26(2):197–202
    • View reference on publisher's website
    • View reference on PubMed
  23. Ho JT, Al-Musalhi H, Chapman MJ et al (2006) Septic shock and sepsis: a comparison of total and free plasma cortisol levels. J Clin Endocrinol Metab 91(1):105–114
    • View reference on publisher's website
    • View reference on PubMed
  24. Ospina NS, Al Nofal A, Bancos I et al (2016) ACTH stimulation tests for the diagnosis of adrenal insufficiency: systematic review and meta-analysis. J Clin Endocrinol Metab 101(2):427–434
    • View reference on publisher's website
    • View reference on PubMed
  25. Moraes RB, Friedman G, Tonietto T, Saltz H, Czepielewski M (2012) Comparison of low and high dose cosyntropin stimulation tests in the diagnosis of adrenal insufficiency in septic shock patients. Horm Metab Res 44(4):296–301
    • View reference on publisher's website
    • View reference on PubMed
  26. Schneider AJ, Voerman HJ (1991) Abrupt hemodynamic improvement in late septic shock with physiological doses of glucocorticoids. Intensive Care Med 17:436–437
  27. Baldwin WA, Allo M (1993) Occult hypoadrenalism in critically ill patients. Arch Surg 128:673–676
    • View reference on publisher's website
    • View reference on PubMed
  28. Annane D, Bellissant E, Sébille V et al (1998) Impaired pressor sensitivity to noradrenaline in septic shock patients with and without impaired adrenal function reserve. Br J Clin Pharmacol 46:589–597
    • View reference on publisher's website
    • View reference on PubMed
  29. Marik PE, Zaloga GP (2003) Adrenal insufficiency during septic shock. Crit Care Med 31:141–145
    • View reference on publisher's website
    • View reference on PubMed
  30. Annane D, Sebille V, Charpentier C et al (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871
    • View reference on publisher's website
    • View reference on PubMed
  31. Arabi YM, Aljumah A, Dabbagh O et al (2010) Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial. CMAJ 182:1971–1977
    • View reference on publisher's website
    • View reference on PubMed
  32. Sprung CL, Annane D, Keh D et al (2008) Hydrocortisone therapy for patients with septic shock. N Engl J Med 358:111–124
    • View reference on publisher's website
    • View reference on PubMed
  33. Keh D, Trips E, Marx G et al (2016) Effect of hydrocortisone on development of shock among patients with severe sepsis: the HYPRESS randomized clinical trial. JAMA 316:1775–1785
    • View reference on publisher's website
    • View reference on PubMed
  34. Wira CR, Dodge K, Sather J, Dziura J (2014) Meta-analysis of protocolized goal-directed hemodynamic optimization for the management of severe sepsis and septic shock in the Emergency Department. West J Emerg Med 15:51–59
    • View reference on publisher's website
    • View reference on PubMed
  35. Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y (2015) Corticosteroids for treating sepsis. Cochrane Database Syst Rev 12:CD002243
  36. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29(7):1303–1310
    • View reference on publisher's website
    • View reference on PubMed
  37. Martin GS, Mannino DM, Eaton S, Moss M (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348(16):1546–1554
    • View reference on publisher's website
    • View reference on PubMed
  38. Torio CM, Andrews RM (2011) National Inpatient Hospital Costs: the most expensive conditions by Payer, 2011: Statistical Brief #160. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb–2013 Aug
  39. Fleischmann C, Thomas-Rueddel DO, Hartmann M et al (2016) Hospital incidence and mortality rates of sepsis. Dtsch Arztebl Int 113(10):159–166
    • View reference on PubMed
  40. Annane D, Bellisant E, Cavaillon JM (2005) Septic shock. Lancet 365(9453):63–78
    • View reference on publisher's website
    • View reference on PubMed
  41. Prigent H, Maxime V, Annane D (2004) Clinical review: corticotherapy in sepsis. Crit Care 8(2):122–129
    • View reference on publisher's website
    • View reference on PubMed
  42. Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y (2015) Corticosteroids for treating sepsis. Cochrane Database Syst Rev. 12:CD002243
  43. Gibbison B, López-López JA, Higgins JP, Miller T, Angelini GD, Lightman SL, Annane D (2017) Corticosteroids in septic shock: a systematic review and network meta-analysis. Crit Care 21(1):78
    • View reference on publisher's website
    • View reference on PubMed
  44. O’Hearn K, McNally D, Choong k, On behalf of the Canadian Critical Care Trials Group et al (2016) Steroids in fluid and/or vasoactive infusion dependent pediatric shock: study protocol for a randomized controlled trial. Trials 17:238
    • View reference on publisher's website
    • View reference on PubMed
  45. Menon K, McNally D, O’Hearn K, Canadian Critical Care Trials Group et al (2017) A randomized controlled trial of corticosteroids in pediatric septic shock: a pilot feasibility study. Pediatr Crit Care Med 18(6):505–512
    • View reference on publisher's website
    • View reference on PubMed
  46. Tongyoo S, Permpikul C, Mongkolpun W, Vattanavanit V, Udompanturak S, Kocak M, Meduri GU (2016) Hydrocortisone treatment in early sepsis-associated acute respiratory distress syndrome: results of a randomized controlled trial. Crit Care 20(1):329
    • View reference on publisher's website
    • View reference on PubMed
  47. El-Nawawy A, Khater D, Omar H, Wali Y (2017) Evaluation of early corticosteroid therapy in management of pediatric septic shock in pediatric intensive care patients: a randomized clinical study. Pediatr Infect Dis J 36(2):155–159
    • View reference on publisher's website
    • View reference on PubMed
  48. Annane D, Brun Buisson C, Cariou A, The APROCCHSS Investigators for the TRIGGERSEP Network et al (2016) Design and conduct of the activated protein C and corticosteroids for human septic shock (APROCCHSS) trial. Ann Intensive Care 6:43
    • View reference on publisher's website
    • View reference on PubMed
  49. Ranieri VM, Thompson BT, Barie PS et al (2013) Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med 366(22):2055–2064
    • View reference on publisher's website
  50. Venkatesh B, Myburgh J, Finfer S et al (2013) The ADRENAL study protocol: adjunctive corticosteroid treatment in critically ill patients with septic shock. Crit Care Resusc 15(2):83–88
    • View reference on PubMed
  51. Bellani G, Laffey JG, Pham T, LUNG SAFE Investigators; ESICM Trials Group et al (2016) Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 315(8):788–800
    • View reference on publisher's website
    • View reference on PubMed
  52. Angus DC, Clermont G, Linde-Zwirble WT, Musthafa AA, Dremsizov TT, Lidicker J, Lave JR, NO-06 Investigators (2006) Healthcare costs and long-term outcomes after acute respiratory distress syndrome: a phase III trial of inhaled nitric oxide. Crit Care Med 34(12):2883–2890
    • View reference on publisher's website
    • View reference on PubMed
  53. Hill AD, Fowler RA, Burns KE et al (2017) Long-term outcomes and health care utilization after prolonged mechanical ventilation. Ann Am Thorac Soc 14(3):355–362
    • View reference on publisher's website
    • View reference on PubMed
  54. Herridge MS, Chu LM, Matte A, RECOVER Program Investigators (Phase 1: towards RECOVER); Canadian Critical Care Trials Group et al (2016) The RECOVER program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation. Am J Respir Crit Care Med 194(7):831–844
    • View reference on publisher's website
    • View reference on PubMed
  55. Meduri GU, Headley AS, Golden E et al (1998) Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA 280:159–165
    • View reference on publisher's website
    • View reference on PubMed
  56. Steinberg KP, Hudson LD, Goodman RB, Hough CL, Lanken PN, Hyzy R, Thompson BT, Ancukiewicz M, National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network (2006) Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med 354(16):1671–1684
    • View reference on publisher's website
    • View reference on PubMed
  57. Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, Gibson M, Umberger R (2007) Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest 131(4):954–963
    • View reference on publisher's website
    • View reference on PubMed
  58. Rezk NA, Ibrahim AM (2013) Effects of methylprednisolone in early ARDS. Egypt J Chest Dis Tuberc 6291:167–172
    • View reference on publisher's website
  59. Confalonieri M, Urbino R, Potena A, Piattella M, Parigi P, Puccio G, Della Porta R, Giorgio C, Blasi F, Umberger R, Meduri GU (2005) Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 171(3):242–248
    • View reference on publisher's website
    • View reference on PubMed
  60. Annane D, Sébille V, Bellissant E, Ger-Inf-05 Study Group (2006) Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med 34(1):22–30
    • View reference on publisher's website
    • View reference on PubMed
  61. Meduri GU, Bridges L, Shin MC et al (2016) Prolonged glucocorticoid treatment is associated with improved ARDS outcomes: analysis of individual patients’ data from four randomized trials and trial-level meta-analysis of the updated literature. Intensive Care Med 42(5):829–840
  62. Meduri GU, Eltorky MA (2015) Understanding ARDS-associated fibroproliferation. Intensive Care Med 41(3):517–520
  63. Greos LS, Vichyanond P, Bloedow DC, Irvin CG, Larsen GL, Szefler SJ, Hill MR (1991) Methylprednisolone achieves greater concentrations in the lung than prednisolone. A pharmacokinetic analysis. Am Rev Respir Dis 144(3):586–592
    • View reference on publisher's website
    • View reference on PubMed
  64. Hoen S, Asehnoune K, Brailly-Tabard S et al (2002) Cortisol response to corticotropin stimulation in trauma patients: influence of hemorrhagic shock. Anesthesiology 97(4):807–813
    • View reference on publisher's website
    • View reference on PubMed
  65. Roquilly A, Mahe PJ, Seguin P et al (2011) Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study. JAMA 305(12):1201–1209
    • View reference on publisher's website
    • View reference on PubMed
  66. Asehnoune K, Seguin P, Allary J, Corti-TC Study Group et al (2014) Hydrocortisone and fludrocortisone for prevention of hospital-acquired pneumonia in patients with severe traumatic brain injury (Corti-TC): a double-blind, multicentre phase 3, randomised placebo-controlled trial. Lancet Respir Med 2(9):706–716
    • View reference on publisher's website
    • View reference on PubMed

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement