Annane Djillali, Pastores Stephen M, Rochwerg Bram, Arlt Wiebke, Balk Robert A, Beishuizen Albertus, Briegel Josef, Carcillo Joseph, Christ-Crain Mirjam, Cooper Mark S, Marik Paul E, Umberto Meduri Gianfranco, Olsen Keith M, Rodgers Sophia C, Russell James A, Van den Berghe Greet
General ICU Department, Raymond Poincaré Hospital (APHP), Health Science.
Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Crit Care Med. 2017 Dec;45(12):2078-2088. doi: 10.1097/CCM.0000000000002737.
To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.
A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.
DESIGN/METHODS: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.
The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of < 9 μg/dL) after cosyntropin (250 μg) administration and a random plasma cortisol of < 10 μg/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).
Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.
更新2008年关于成人及儿童危重症相关皮质类固醇功能不全（CIRCI）诊断与管理的共识声明。
由16名危重症医学、内分泌学及指南制定方法领域的国际专家组成的多专业特别工作组，他们均为危重症医学会和/或欧洲重症监护医学会成员。
设计/方法：这些建议基于2008年文件的汇总证据，以及对2008年至2017年相关研究更新的系统评价中的最新发现，并采用推荐分级评估、制定与评价（GRADE）方法制定。每项建议的强度分为强烈或有条件，证据质量根据个体研究设计、偏倚风险、结果一致性以及证据的直接性和精确性等因素从高到极低进行评级。建议的批准需要至少80%的特别工作组成员同意。
特别工作组未能就一项能可靠诊断CIRCI的单一检测方法达成一致，不过临床医生可使用促肾上腺皮质激素（250μg）给药后60分钟时的皮质醇变化量（Δ皮质醇，基线皮质醇变化量<9μg/dL）以及随机血浆皮质醇<10μg/dL。我们建议不要使用游离皮质醇或唾液皮质醇水平来替代血浆总皮质醇（有条件，证据质量极低）。对于特定情况的治疗，我们建议对于液体复苏及中到高剂量血管升压药治疗无效的感染性休克患者，静脉注射氢化可的松<400mg/天，全剂量使用≥3天（有条件，证据质量低）。我们建议无休克的成年脓毒症患者不使用皮质类固醇（有条件推荐，证据质量中等）。我们建议对于早期中度至重度急性呼吸窘迫综合征（PaO2/FiO2<200且发病14天内）患者使用静脉注射甲泼尼龙1mg/（kg·天）（有条件，证据质量中等）。不建议对重大创伤患者使用皮质类固醇（有条件，证据质量低）。
一个多专业特别工作组已制定出关于在脓毒症和感染性休克、急性呼吸窘迫综合征及重大创伤的危重症患者中使用皮质类固醇的循证建议。
