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

Authors

DOI:

https://doi.org/10.15605/jafes.037.01.03

Keywords:

critical illness-related corticosteroid insufficiency, shock, corticosteroid, cortisol

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.

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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

References

Rivas AM, Sotello D. Critical illness-related corticosteroid insufficiency: What we know and what we don’t know. Southwest Respir Crit Care Chron. 2019; 7(31):44-8. https://doi.org/10.12746/swrccc.v7i31.595.

Song JH, Kim JH, Lee SM, Lee J. Prognostic implication of adrenocortical response during the course of critical illness. Acute Crit Care. 2019;34(1):38-45. https://pubmed.ncbi.nlm.nih.gov/31723903. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6849045. https://doi.org/10.4266/acc.2018.00339.

Salgado DR, Verdeal JC, Rocco JR. Adrenal function testing in patients with septic shock. Crit Care. 2006;10(5):R149. https://pubmed.ncbi.nlm.nih.gov/17062164. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1751047. https://doi.org/10.1186/cc5077.

Annane D, Pastores SM, Rochwerg B, Arlt W, et al. 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. Intensive Care Med. 2017;43(12):1751–63. https://pubmed.ncbi.nlm.nih.gov/28940011. https://doi.org/10.1007/s00134-017-4919-5.

Philippine Society for Microbiology and Infectious Diseases. Clinical Practice Guidelines for Sepsis and Septic Shock in Adults in the Philippines. Accessed on March 7, 2020. https://www.psmid.org/executive-summary-cpg-for-sepsis-and-septic-shock-in-adults-in-the-philippines-2020/.

Karir V, Cooke CR, Andersson L, Caldwell E, Rubenfeld GD. Practice variability in the assessment and treatment of critical illness-related corticosteroid insufficiency. J Crit Care. 2010;25(2): 363.e9-363.e14. https://pubmed.ncbi.nlm.nih.gov/19781894. https://doi.org/10.1016/j.jcrc.2009.07.007.

Cutillar CS, Fojas M, Ramirez J, et al. Adrenal Responsiveness to the 10-mcg ACTH Stimulation Test Among Critically Ill Patients on Inotropic Support Admitted at the Philippine General Hospital. 2005. Unpublished.

Turner W, Merriman LM. Clinical protocols. Clinical skills in treating the foot. 2nd ed. Churchill Livingstone; 2005.

Margolis CZ. Uses of clinical algorithms. 1983;249(5):627-32. https://pubmed.ncbi.nlm.nih.gov/6336813.

Eubank BH, Mohtadi NG, Lafave MR, et al. Using the modified Delphi Method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology. BMC Med Res Methodol. 2016;16:56. https://pubmed.ncbi.nlm.nih.gov/27206853. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875724. https://doi.org/10.1186/s12874-016-0165-8.

Lavelle J, Schast A, Keren R. Standardizing care processes and improving quality using pathways and continuous quality improvement. Curr Treat Options Peds. 2015;1:347-58. https://doi.org/10.1007/s40746-015-0026-4.

Custer RL, Scarcella JA, Stewart BR. The modified Delphi technique - A rotational modification. J Career Tech Edu. 1999;15:50–8. https://doi.org/10.21061/jcte.v15i2.702,

Jünger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliat Med. 2017;31(8):684-706. https://pubmed.ncbi.nlm.nih.gov/28190381. https://doi.org/10.1177/0269216317690685.

Marik PE. Critical illness-related corticosteroid insufficiency. Chest. 2009;135(1):181-93. https://pubmed.ncbi.nlm.nih.gov/19136406. https://doi.org/10.1378/chest.08-1149.

Ducrocq N, Biferi P, Girerd N, et al. Critical Illness-Related Corticosteroid Insufficiency in cardiogenic shock patients: Prevalence and prognostic role. Shock. 2018;50(4):408-13. https://pubmed.ncbi.nlm.nih.gov/29280926. https://doi.org/10.1097/SHK.0000000000001090.

Lamontagne F, Rochwerg B, Lytvyn L, et al. Corticosteroid therapy for sepsis: A clinical practice guideline BMJ. 2018;362:k3284. https://pubmed.ncbi.nlm.nih.gov/30097460. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083439. https://doi.org/10.1136/bmj.k3284.

Ok YJ, Lim JY, Jung SH. Critical Illness-Related Corticosteroid Insufficiency in patients with low cardiac output syndrome after cardiac surgery. Korean J Thorac Cardiovasc Surg. 2018;51(2):109-13. https://pubmed.ncbi.nlm.nih.gov/29662808. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5894574. https://doi.org/10.5090/kjtcs.2018.51.2.109.

Marik, PE, Pastores, Sm, Annane, D. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: Consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008;36(6):1937-49. https://pubmed.ncbi.nlm.nih.gov/18496365. https://doi.org/10.1097/CCM.0b013e31817603ba.

Sosa S, Danilowicz K, Rizzo LFL. Adrenal axis in critical illness. Medicina (B Aires). 2021;81(1):69-75. https://pubmed.ncbi.nlm.nih.gov/33611247.

Ashrafuzzaman SM. Adrenal insufficiency in critically ill patients. Bangladesh Crit Care J. 2015;3(1):27. https://doi.org/10.3329/bccj.v3i1.24101.

Duffield C. The Delphi technique: A comparison of results obtained using two expert panels. Int J Nurs Stud. 1993;30(3):227-37. https://pubmed.ncbi.nlm.nih.gov/8335432. https://doi.org/10.1016/0020-7489(93)90033-q

Vogel C, Zwolinsky S, Griffiths C, Hobbs M, Henderson E, Wilkins E. A Delphi study to build consensus on the definition and use of big data in obesity research. Int J Obes. 2019;43(12):2573-86. https://pubmed.ncbi.nlm.nih.gov/30655580. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892733. https://doi.org/10.1038/s41366-018-0313-9.

Taylor E. We agree, don’t we? The Delphi Method for Health Environments Research. HERD. 2020;13(1):11-23. https://pubmed.ncbi.nlm.nih.gov/31887097. https://doi.org/10.1177/1937586719887709.

Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: A systematic review. PLoS One. 2011;6(6):e20476. https://pubmed.ncbi.nlm.nih.gov/21694759. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111406. https://doi.org/10.1371/journal.pone.0020476.

Meshkat B, Cowman S, Gethin G, et al. Using an e-Delphi technique in achieving consensus across disciplines for developing best practice in day surgery in Ireland. J Hosp Adm. 2014;3(4):1–8. https://doi.org/10.5430/jha.v3n4p1.

Veugelers R, Gaakeer MI, Patka P, Huijsman R. Improving design choices in Delphi studies in medicine: The case of an exemplary physician multi-round panel study with 100% response. BMC Med Res Methodol. 2020;20(1):156. https://pubmed.ncbi.nlm.nih.gov/32539717. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294633. https://doi.org/10.1186/s12874-020-01029-4.

Powell C. The Delphi technique: Myths and realities. J Adv Nurs. 2003;41(4):76-82. https://pubmed.ncbi.nlm.nih.gov/12581103. https://doi.org/10.1046/j.1365-2648.2003.02537.x.

Boel A, Navarro-Compán V, Landewé R, van der Heijde D. Two different invitation approaches for consecutive rounds of a Delphi survey led to comparable final outcome. J Clin Epidemiol. 2021;129:31-9. https://pubmed.ncbi.nlm.nih.gov/32991995. https://doi.org/10.1016/j.jclinepi.2020.09.034.

Kasugai D, Nishikimi M, Nishida K, et al. Timing of administration of epinephrine predicts the responsiveness to epinephrine in norepinephrine-refractory septic shock: A retrospective study. J Intensive Care. 2019;7:20. https://pubmed.ncbi.nlm.nih.gov/30992991. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6451296. https://doi.org/10.1186/s40560-019-0377-1.

Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013;9(1):30. https://pubmed.ncbi.nlm.nih.gov/23947590. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115. https://doi.org/10.1186/1710-1492-9-30.

American Diabetes Association. Diabetes care in the hospital: Standards of medical care in diabetes care-2019. Diabetes Care. 2019;42(Suppl 1):S173-81. https://pubmed.ncbi.nlm.nih.gov/30559241. https://doi.org/10.2337/dc19-S015.

Endocrinology Handbook Endocrine Unit Imperial College. Healthcare NHS Trust Charing Cross, Hammersmith and St. Mary’s Hospitals Updated; 2010. Available in https://pdf4pro.com/amp/view/endocrinology-handbook-endocrine-unit-imperial-5e9d1.html.

Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-77. https://pubmed.ncbi.nlm.nih.gov/28101605. https://doi.org/10.1007/s00134-017-4683-6.

El-Farhan N, Rees DA, Evans C. Measuring cortisol in serum, urine and saliva - Are our assays good enough? Ann Clin Biochem. 2017;54(3):308-22. https://pubmed.ncbi.nlm.nih.gov/28068807. https://doi.org/10.1177/0004563216687335.

Annane D, Sébille V, Troché G, Raphaël JC, Gajdos P, Bellissant E. A 3-level prognostic classifiation in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000;283(8):1038-45. https://pubmed.ncbi.nlm.nih.gov/10697064. https://doi.org/10.1001/jama.283.8.1038.

Roquilly A, Mahe PJ, Seguin P, et al. Hydrocortisone therapy for patients with multiple trauma: The randomized controlled HYPOLYTE study. JAMA. 2011;305(12):1201-9. https://pubmed.ncbi.nlm.nih.gov/21427372. https://doi.org/10.1001/jama.2011.360.

Published

2022-02-26

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. https://doi.org/10.15605/jafes.037.01.03

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