Adrenal dysfunction in critical care settings

Abstract

Adrenal insufficiency (AI) is a frequently discussed but inadequately understood condition among critically ill patients. Increased glucocorticoid action is an essential component of the stress response. Dysfunction of the HPA axis in critical illness may be best described by the term critical illness-related corticosteroid insufficiency (CIRCI), in preference to terms like absolute or relative adrenal insufficiency. Most of the research about CIRCI has focused on patients with septic shock and acute respiratory distress syndrome (ARDS). The diagnosis of CIRCI relies on clinical suspicion and ACTH stimulation test results. Adjunctive corticosteroids may be considered in patients with septic shock who have responded poorly to volume resuscitation and catecholamines, and for patients with ARDS. No high-quality data supporting such intervention for children is currently available. Routine ACTH testing is not recommended to identify this subset of patients with septic shock who should receive hydrocortisone therapy. Given the lack of consistent benefit and likely under appreciation of the adverse effects of this drug class, clinicians should maintain equipoise for well-designed clinical interventional trials addressing both the potential benefits and risks of adjunctive corticosteroids prescribed for septic shock and ARDS.

Keywords

• adrenal insufficiency
• critical illness related corticosteroid insufficiency
• circi
• adrenocorticotropic hormone
• acth
• glucocorticoids
• corticosteroids
• septic shock
• acute respiratory distress syndrome
• critical illness