The Development of a Protocol for Critical Illness-Related Corticosteroid Insufficiency (CIRCI) at a Tertiary Hospital

Abstract

Objectives The diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) remains a challenge. This initiative aimed to develop a protocol for the diagnosis and management of CIRCI which will facilitate informed decision-making among clinicians through consensus-building among a multi-disciplinary team. Methodology This was a single-center, qualitative study which utilized the modified Delphi method, consisting of a sequential iterative process with two rounds of voting. A cut-off value of 70% was set as the threshold for reaching consensus. Results The protocol on the diagnosis and management of CIRCI was approved after two rounds of voting, with all the components reaching 83.3%-100% agreement. This protocol on CIRCI provided a framework for the clinical approach to refractory shock. It was advocated that all cases of probable CIRCI should immediately be started on hydrocortisone at 200 mg/day. The definitive diagnosis of CIRCI is established through a random serum cortisol <10 mcg/dL or increase in cortisol of <9 mcg/dL at 60 minutes after a 250 mcg ACTH stimulation test in patients with indeterminate random cortisol levels. Conclusion The presence of refractory shock unresponsive to fluid resuscitation and vasopressors should warrant the clinical suspicion for the existence of CIRCI and should trigger a cascade of management strategies.

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) among Patients with COVID-19 at a Tertiary Hospital: Clinical Characteristics and Outcomes

“…27 In this cohort of COVID-19-positive patients, the median cortisol level was at 25.26 mcg/dl compared to 24.15 mcg/dl for the non-COVID subgroup in the same institution. 28 However, a notable factor that ought to be considered is that not all patients in this cohort had random serum cortisol results because, in most of the patients, CIRCI was diagnosed based on the presence of refractory shock and subsequent therapeutic response to corticosteroids. The small sample size of patients with cortisol results could have served as a barrier in detecting significantly low cortisol levels in this cohort.…”

Critical illness-related corticosteroid insufficiency (CIRCI) in paediatric patients: a diagnostic and therapeutic challenge

“…Additionally, the question about the duration of steroid supplementation is still debated. A recent work, by Arcellana et al [ 37 ] indicated that 200 mg/day hydrocortisone should be given for at least 72 h and up to 7 days, to have a significant benefit [ 1 , 38 ], but no univocal indication is provided about this topic.…”

Hypothalamic-Pituitary Axis Function and Adrenal Insufficiency in COVID-19 Patients

“…CIRCI describes the impairment of HPA axis during critical illness, and in most of the cases, it is associated with dysregulation of the HPA axis, tissue corticosteroid resistance, and altered cortisol metabolism. In clinical practice, refractory shock unresponsive to fluid resuscitation and vasopressors might suggest the presence of CIRCI, and it has been suggested that patients with probable CIRCI should immediately be treated with glucocorticoids [ 30 ]. Moreover, current evidence indicates that there are also some changes resulting in mineralocorticoid dysfunction during critical illness, and hyperreninemic hypoaldosteronism has been demonstrated.…”