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Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

Annane, Djillali MD, PhD1; Pastores, Stephen M. MD, FCCM2; Rochwerg, Bram MD3; Arlt, Wiebke MD, DSc, FRCP4; Balk, Robert A. MD, MCCM5; Beishuizen, Albertus MD, PhD6; Briegel, Josef MD, PhD7; Carcillo, Joseph MD, FCCM8; Christ-Crain, Mirjam MD, PhD9; Cooper, Mark S. MD10; Marik, Paul E. MD, FCCM11; Umberto Meduri, Gianfranco MD12; Olsen, Keith M. PharmD, FCCM13; Rodgers, Sophia C. RN, MSN, ACNP, FCCM14; Russell, James A. MD15; Van den Berghe, Greet MD, PhD16

doi: 10.1097/CCM.0000000000002737
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Objective: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.

Participants: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.

Design/Methods: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.

Results: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of < 9 μg/dL) after cosyntropin (250 μg) administration and a random plasma cortisol of < 10 μg/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).

Conclusions: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.

Supplemental Digital Content is available in the text.

1General ICU Department, Raymond Poincaré Hospital (APHP), Health Science.

2Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

3Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.

4Institute of Metabolism and Systems Research (IMSR), University of Birmingham and Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK.

5Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA.

6Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands.

7Anesthesiology and Critical Care Medicine, Klinik für Anästhesiologie, Klinikum der Universität, Munich, Germany.

8Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

9Department of Endocrinology, Diabetology and Metabolism, Clinical Research, University Hospital Basel, Basel, Switzerland.

10Department of Endocrinology, Concord Hospital, University of Sidney, Sidney, NSW, Australia.

11Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.

12Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Memphis Veterans Affairs Medical Center, Memphis, TN, USA.

13College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

14Clinical Adjunct Faculty, University of New Mexico and Sandoval Regional Medical Center, Albuquerque, NM, USA.

15Division of Critical Care Medicine, Centre for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada.

16Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University and Hospitals, Louvain, Belgium.

Dr. Djillali Annane and Dr. Stephen M. Pastores were co-chairs of the task force and contributed equally to this work.

Dr. Annane has been involved with research relating to this guideline. Dr. Pastores participates in the American College of Physicians: Speaker at ACP Critical Care Update Precourse, the American College of Chest Physicians (CHEST) (faculty speaker at Annual Congress), the American Thoracic Society (ATS): Moderator at Annual Meeting, the European Society of Intensive Care Medicine (EISCM) (co-chair of Corticosteroid Guideline in collaboration with SCCM), and the Korean Society of Critical Care Medicine (co-director and speaker at Multiprofessional Critical Care Board Review Course). He has spoken on the topic of corticosteroid use in critical illness and specifically in sepsis at the International Symposium in Critical and Emergency Medicine in March 2017. Dr. Arlt participates in the Society for Endocrinology UK (Chair of the Clinical Committee, member of Council, member of the Nominations Committee) and the Endocrine Society USA (member, Publication Core Committee). Dr. Briegel participates in the European Society of Intensive Care Medicine, the Deutsche interdisziplinäre Vereinigung Intensivmedizin, and the Deutsche Gesellschaft für Anästhesie und Intensivmedizin, and he has given lectures and talks on hydrocortisone treatment of septic shock. Dr. Cooper participates in a range of specialist societies relating to endocrinology and bone disease. Dr. Meduri disclosed he is a government employee. Dr. Olsen participates in the American College of Clinical Pharmacy (grant review committee), and he represents the American Society of Health-System Pharmacists on the National Quality Forum for Surgery Measures. Dr. Rochwerg disclosed he is a methodologist for ATS, CBS, ESCIM, ASH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Supplemental digital content is available for this article which includes evidence profiles.

This article is being simultaneously published in Critical Care Medicine and Intensive Care Medicine. ICM DOI: 10.1007/s00134-017-4919-5

This article is linked to another article entitled “Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review From a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM)” published in parallel.

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