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Chapter 212. Critical Illness–Related Corticosteroid Insufficiency (CIRCI)

Nirav Mistry, MD; Adel Bassily-Marcus, MD, FCCP, FCCM

  • Critical illness–related corticosteroid insufficiency (CIRCI) is defined as inadequate corticosteroid activity for the severity of the patient's illness

  • Possible complications from corticosteroid therapy:
    • Immune suppression
    • Increased risk of infections (wound, nosocomial)
    • Impaired wound healing
    • Hyperglycemia
    • Myopathy
    • Psychosis
    • Hypokalemic metabolic acidosis
    • Further HPA and glucocorticoid receptor suppression

Table 212-1 Etiology, Symptoms, and Diagnosis of Adrenal Insufficiency in Critically Ill Patients
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Table 212-1 Etiology, Symptoms, and Diagnosis of Adrenal Insufficiency in Critically Ill Patients
  • Etiology
    • Structural damage to adrenals
    • Drugs
    • Primary and secondary etiologies
    • Reversible hypothalamic–pituitary–adrenal dysfunction
  • Clinical manifestations
    • Primarily results in shock refractory to fluids and vasopressors
    • Consider in patients with progressive ALI/ARDS
    • Possible eosinophilia and hypoglycemia
    • Uncommonly—hyponatremia and hyperkalemia
  • Diagnosis
    • ACTH stimulation test no longer recommended
    • Random cortisol level <10 μg/dL
    • Alternative: cosyntropin stimulation test
      • Check cortisol level before 250 μg cosyntropin administration and then 30 and 60 min after
      • Diagnostic if change in cortisol is <9 μg/dL (difference between pre- and post-cosyntropin administration)
Figure 212-1. Algorithm for the Management of Patient with Suspected Critical Illness–Related Corticosteroid Insufficiency (CIRCI)
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1. Marik P. Critical illness-related corticosteroid insufficiency. Chest. 2009 Jan;135(1):181–193.   [PubMed: 19136406]
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2. Marik PE, Pastores SM, Ananne D, 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 Jun;36(6):1937–1949.   [PubMed: 18496365]
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3. Dellinger P, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for the management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan;36:296–327.   [PubMed: 18158437]

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