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Force by the American College of Critical Care Medicine.

Crit Care Med. 2008 Jun;36(6):1937-49.



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 microg/dL after

adrenocorticotrophic hormone (250 microg) administration or a random total

cortisol of < 10 microg/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 > or = 7 days is recommended for septic shock.

Methylprednisolone in a dose of 1 mg x kg(-1) x day(-1) for > or = 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,

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