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

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Anna Elvira Arcellana
Kenneth Wilson Lim
Marlon Arcegono
Cecilia Jimeno


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.


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How to Cite
Arcellana, A. E., Lim, K. W. ., Arcegono, M. ., & Jimeno, C. . (2022). The Development of a Protocol for Critical Illness-Related Corticosteroid Insufficiency (CIRCI) at a Tertiary Hospital. Journal of the ASEAN Federation of Endocrine Societies, 37(1), 14–23.
Original Articles
Author Biographies

Anna Elvira Arcellana, University of the Philippines Manila-Philippine General Hospital

Division of Endocrinology, Diabetes and Metabolism

Kenneth Wilson Lim, University of the Philippines Manila, Philippine General Hospital

Division of Pulmonary Medicine

Marlon Arcegono, University of the Philippines Manila, Philippine General Hospital

Division of Infectious Disease

Cecilia Jimeno, University of the Philippines Manila, Philippine General Hospital

Division of Endocrinology, Diabetes, and Metabolism


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