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

Paul E. Marik, Stephen M. Pastores, Djillali Annane, Gianfranco Meduri, Charles L. Sprung, Wiebke Arlt, Didier Keh, Josef Briegel, Albertus Beishuizen, Ioanna Dimopoulou, Stylianos Tsagarakis, Mervyn Singer, George P. Chrousos, Gary Zaloga, Faran Bokhari, Michael Vogeser

Research output: Contribution to journalArticle

593 Citations (Scopus)

Abstract

OBJECTIVE:: To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients. PARTICIPANTS:: A multidisciplinary, multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. In addition, international experts in endocrinology were invited to participate. DESIGN/METHODS:: The task force members reviewed published literature and provided expert opinion from which the consensus was derived. The consensus statements were developed using a modified Delphi methodology. The strength of each recommendation was quantified using the Modified GRADE system, which classifies recommendations as strong (grade 1) or weak (grade 2) and the quality of evidence as high (grade A), moderate (grade B), or low (grade C) based on factors that include the study design, the consistency of the results, and the directness of the evidence. RESULTS:: The task force coined the term critical illness-related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness. Critical illness-related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted proinflammatory response. Critical illness-related corticosteroid insufficiency should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents, particularly in the setting of sepsis. At this time, the diagnosis of tissue corticosteroid resistance remains problematic. Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of <9 μg/dL after adrenocorticotrophic hormone (250 μg) administration or a random total cortisol of <10 μg/dL. The benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (Pao2/Fio2 of <200 and within 14 days of onset). The adrenocorticotrophic hormone stimulation test should not be used to identify those patients with septic shock or acute respiratory distress syndrome who should receive glucocorticoids. Hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day (10 mg/hr) for ≥7 days is recommended for septic shock. Methylprednisolone in a dose of 1 mg•kg•day for ≥14 days is recommended in patients with severe early acute respiratory distress syndrome. Glucocorticoids should be weaned and not stopped abruptly. Reinstitution of treatment should be considered with recurrence of signs of sepsis, hypotension, or worsening oxygenation. Dexamethasone is not recommended to treat critical illness-related corticosteroid insufficiency. The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation. CONCLUSION:: Evidence-linked consensus statements with regard to the diagnosis and management of corticosteroid deficiency in critically ill patients have been developed by a multidisciplinary, multispecialty task force.

Original languageEnglish (US)
Pages (from-to)1937-1949
Number of pages13
JournalCritical Care Medicine
Volume36
Issue number6
DOIs
StatePublished - Jan 1 2008

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Advisory Committees
Critical Care
Critical Illness
Adrenal Cortex Hormones
Medicine
Glucocorticoids
Adult Respiratory Distress Syndrome
Septic Shock
Hydrocortisone
Adrenal Insufficiency
Adrenocorticotropic Hormone
Sepsis
Severe Acute Respiratory Syndrome
Endocrinology
Liver Failure
Methylprednisolone
Expert Testimony
Vasoconstrictor Agents
Pancreatitis
Hypotension

All Science Journal Classification (ASJC) codes

  • Critical Care and Intensive Care Medicine

Cite this

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. / Marik, Paul E.; Pastores, Stephen M.; Annane, Djillali; Meduri, Gianfranco; Sprung, Charles L.; Arlt, Wiebke; Keh, Didier; Briegel, Josef; Beishuizen, Albertus; Dimopoulou, Ioanna; Tsagarakis, Stylianos; Singer, Mervyn; Chrousos, George P.; Zaloga, Gary; Bokhari, Faran; Vogeser, Michael.

In: Critical Care Medicine, Vol. 36, No. 6, 01.01.2008, p. 1937-1949.

Research output: Contribution to journalArticle

Marik, PE, Pastores, SM, Annane, D, Meduri, G, Sprung, CL, Arlt, W, Keh, D, Briegel, J, Beishuizen, A, Dimopoulou, I, Tsagarakis, S, Singer, M, Chrousos, GP, Zaloga, G, Bokhari, F & Vogeser, M 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', Critical Care Medicine, vol. 36, no. 6, pp. 1937-1949. https://doi.org/10.1097/CCM.0b013e31817603ba
Marik, Paul E. ; Pastores, Stephen M. ; Annane, Djillali ; Meduri, Gianfranco ; Sprung, Charles L. ; Arlt, Wiebke ; Keh, Didier ; Briegel, Josef ; Beishuizen, Albertus ; Dimopoulou, Ioanna ; Tsagarakis, Stylianos ; Singer, Mervyn ; Chrousos, George P. ; Zaloga, Gary ; Bokhari, Faran ; Vogeser, Michael. / 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. In: Critical Care Medicine. 2008 ; Vol. 36, No. 6. pp. 1937-1949.
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T1 - Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients

T2 - Consensus statements from an international task force by the American College of Critical Care Medicine

AU - Marik, Paul E.

AU - Pastores, Stephen M.

AU - Annane, Djillali

AU - Meduri, Gianfranco

AU - Sprung, Charles L.

AU - Arlt, Wiebke

AU - Keh, Didier

AU - Briegel, Josef

AU - Beishuizen, Albertus

AU - Dimopoulou, Ioanna

AU - Tsagarakis, Stylianos

AU - Singer, Mervyn

AU - Chrousos, George P.

AU - Zaloga, Gary

AU - Bokhari, Faran

AU - Vogeser, Michael

PY - 2008/1/1

Y1 - 2008/1/1

N2 - OBJECTIVE:: To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients. PARTICIPANTS:: A multidisciplinary, multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. In addition, international experts in endocrinology were invited to participate. DESIGN/METHODS:: The task force members reviewed published literature and provided expert opinion from which the consensus was derived. The consensus statements were developed using a modified Delphi methodology. The strength of each recommendation was quantified using the Modified GRADE system, which classifies recommendations as strong (grade 1) or weak (grade 2) and the quality of evidence as high (grade A), moderate (grade B), or low (grade C) based on factors that include the study design, the consistency of the results, and the directness of the evidence. RESULTS:: The task force coined the term critical illness-related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness. Critical illness-related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted proinflammatory response. Critical illness-related corticosteroid insufficiency should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents, particularly in the setting of sepsis. At this time, the diagnosis of tissue corticosteroid resistance remains problematic. Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of <9 μg/dL after adrenocorticotrophic hormone (250 μg) administration or a random total cortisol of <10 μg/dL. The benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (Pao2/Fio2 of <200 and within 14 days of onset). The adrenocorticotrophic hormone stimulation test should not be used to identify those patients with septic shock or acute respiratory distress syndrome who should receive glucocorticoids. Hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day (10 mg/hr) for ≥7 days is recommended for septic shock. Methylprednisolone in a dose of 1 mg•kg•day for ≥14 days is recommended in patients with severe early acute respiratory distress syndrome. Glucocorticoids should be weaned and not stopped abruptly. Reinstitution of treatment should be considered with recurrence of signs of sepsis, hypotension, or worsening oxygenation. Dexamethasone is not recommended to treat critical illness-related corticosteroid insufficiency. The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation. CONCLUSION:: Evidence-linked consensus statements with regard to the diagnosis and management of corticosteroid deficiency in critically ill patients have been developed by a multidisciplinary, multispecialty task force.

AB - OBJECTIVE:: To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients. PARTICIPANTS:: A multidisciplinary, multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. In addition, international experts in endocrinology were invited to participate. DESIGN/METHODS:: The task force members reviewed published literature and provided expert opinion from which the consensus was derived. The consensus statements were developed using a modified Delphi methodology. The strength of each recommendation was quantified using the Modified GRADE system, which classifies recommendations as strong (grade 1) or weak (grade 2) and the quality of evidence as high (grade A), moderate (grade B), or low (grade C) based on factors that include the study design, the consistency of the results, and the directness of the evidence. RESULTS:: The task force coined the term critical illness-related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness. Critical illness-related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted proinflammatory response. Critical illness-related corticosteroid insufficiency should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents, particularly in the setting of sepsis. At this time, the diagnosis of tissue corticosteroid resistance remains problematic. Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of <9 μg/dL after adrenocorticotrophic hormone (250 μg) administration or a random total cortisol of <10 μg/dL. The benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (Pao2/Fio2 of <200 and within 14 days of onset). The adrenocorticotrophic hormone stimulation test should not be used to identify those patients with septic shock or acute respiratory distress syndrome who should receive glucocorticoids. Hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day (10 mg/hr) for ≥7 days is recommended for septic shock. Methylprednisolone in a dose of 1 mg•kg•day for ≥14 days is recommended in patients with severe early acute respiratory distress syndrome. Glucocorticoids should be weaned and not stopped abruptly. Reinstitution of treatment should be considered with recurrence of signs of sepsis, hypotension, or worsening oxygenation. Dexamethasone is not recommended to treat critical illness-related corticosteroid insufficiency. The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation. CONCLUSION:: Evidence-linked consensus statements with regard to the diagnosis and management of corticosteroid deficiency in critically ill patients have been developed by a multidisciplinary, multispecialty task force.

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