New guideline on treating critical illness-related corticosteroid insufficiency

The guideline from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine is an update to consensus statements on the topic published in 2008.


Two critical care societies recently updated their joint recommendations on critical illness-related corticosteroid insufficiency.

Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients” were developed by experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine as an update to consensus statements on the topic published in 2008. An update was necessary given the importance of evidence-based care and “the widespread use of corticosteroids in critically ill patients, highlighting the need for a valid, reliable, and transparent process of evaluation to support key decisions,” the authors said.

The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although clinicians may use delta cortisol (change in baseline cortisol level at 60 min of <9 µg/dL) after cosyntropin (250 µg) administration and a random plasma cortisol level below 10 µg/dL, they said. The guideline also suggested against using plasma-free cortisol or salivary cortisol level over plasma total cortisol level (conditional recommendation, very low quality of evidence).

Other recommendations include the following:

  • Use IV hydrocortisone, less than 400 mg/day for at least three days, at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional recommendation, low quality of evidence).
  • Don't use corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence).
  • Use IV methylprednisolone, 1 mg/kg of body weight per day, in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 <200 and within 14 days of onset) (conditional recommendation, moderate quality of evidence).
  • Don't use corticosteroids for patients with major trauma (conditional recommendation, low quality of evidence).

The recommendations were published online by Critical Care Medicine on Sept. 21. They were based not only on summarized evidence from the 2008 consensus statements but also on an updated systematic review of relevant studies from 2008 to 2017 published with the guideline.