Hepatic Failure/GI/Endocrine Emergencies
iv.
Patients receiving chronic corticosteroids who have an acute stressor should receive an increased
glucocorticoid dose to prevent adrenal crisis.
| (a) | Recommended dose depends on the level of stress. |
|---|---|
| (b) | In febrile patients, those undergoing major dental procedures, and those undergoing |
invasive diagnostic tests (e.g., colonoscopy), a doubling or tripling of the maintenance dose
for 1–3 days may be sufficient.
| (c) | Patients experiencing severe infection, undergoing major surgery, or presenting with shock |
|---|
should be started on intravenous hydrocortisone 200–300 mg/day, which can be tapered
to their home regimen when they have clinically improved.
Clinical presentation
CIRCI refers to impairment of the hypothalamic-pituitary-adrenal axis during critical illness
as a complication of an underlying disease. Patients most commonly have septic shock but may
also have acute respiratory distress syndrome, cardiac arrest, trauma, or burns.
ii.
Patients with CIRCI often have hypotension refractory to fluids that requires addition of
vasopressors. Laboratory assessment may show hypoglycemia and eosinophilia; hyponatremia
and hyperkalemia are uncommon.
Diagnosis
CIRCI has historically been diagnosed based on either a low serum cortisol concentration or
an inadequate response seen on the cosyntropin stimulation test. Poor reproducibility of the
cosyntropin stimulation test and lack of agreement of commercially available cortisol assays
with analytic standards limit the use of these tests in critically ill patients.
ii.
Despite known limitations, increase in cortisol of less than 9 mg/dL following a cosyntropin
stimulation test is the best predictor of adrenal insufficiency. A serum cortisol value less than 10
mg/dL has high positive predictive value for adrenal insufficiency but low sensitivity.
iii.
Current guidelines for the treatment of CIRCI recommend against using cortisol-based testing
to determine whether a patient is a candidate for corticosteroid therapy.
Management
Corticosteroids should only be given for patients with septic shock and suspected CIRCI who
do not achieve resuscitation goals despite fluid administration and an ongoing vasopressor
requirement.
ii.
Treatment of CIRCI in the setting of septic shock is discussed in the “Shock Syndromes I:
Introduction, Vasodilatory, and Sepsis” chapter. Use of corticosteroids for the treatment of
acute respiratory distress syndrome is discussed in the “Pulmonary Disorders I” chapter.