Acute Crit Care.  2024 Aug;39(3):331-340. 10.4266/acc.2024.00647.

Critical illness-related corticosteroid insufficiency: latest pathophysiology and management guidelines

• Fredrick FC
• Meda AKR
• Singh B
• Jain R

• KMID: 2563522
• DOI: http://doi.org/10.4266/acc.2024.00647

Abstract

Intensive care unit (ICU) admissions in the United States exceed 5.7 million annually, often leading to complications such as post-intensive care syndrome and high mortality rates. Among these challenges, critical illness-related corticosteroid insufficiency (CIRCI) requires emphasis due to its complex, multiple-cause pathophysiology and varied presentations. CIRCI, characterized by adrenal insufficiency during critical illness, presents in up to 30% of ICU patients and may manifest as an exaggerated inflammatory response. Factors such as dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, tissue corticosteroid resistance, and drug-induced suppression contribute to CIRCI. Diagnosis is a complex process, relying on a comprehensive assessment including clinical presentation, laboratory findings, and dynamic stimulatory testing. Treatment involves intensive medical care and exacting glucocorticoid therapy. Recent guidelines advocate for individualized approaches tailored to patient presentation and etiology. Understanding the pathophysiology and treatment of CIRCI is vital for clinicians managing critically ill patients and striving to improve outcomes. This research paper aims to explore the latest developments in the pathophysiology and management of CIRCI.

Keyword

adrenal insufficiency; cortisol-binding globulin; critical illness; critical illness-related corticosteroid insufficiency; hydrocortisone; hypothalamic pituitary adrenal axis

Figure

• 

  Figure 1. Pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). (A) Variation in hypothalamic-pituitary-adrenal (HPA) axis response during critical illness. (B) Altered cortisol metabolism, HPA axis inhibition and peripheral resistance to cortisol. (C) Tissue resistance to corticosteroids. (D) Drug-induced CIRCI. GRα: glucocorticoid receptor alpha; GRβ: glucocorticoid receptor beta.

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