Division of Endocrinology, Diabetes and Metabolism, University of the Philippines Manila, Philippine General Hospital.
Division of Pulmonary Medicine, University of the Philippines Manila, Philippine General Hospital.
J ASEAN Fed Endocr Soc. 2022;37(1):14-23. doi: 10.15605/jafes.037.01.03. Epub 2022 Feb 26.
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.
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.
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.
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.
危重病相关皮质激素不足（CIRCI）的诊断和治疗仍然是一个挑战。本研究旨在制定一个诊断和治疗 CIRCI 的方案，通过多学科团队的共识建立，为临床医生提供决策依据。
这是一项单中心的定性研究，采用改良 Delphi 方法，包括两轮投票的顺序迭代过程。设定 70%的截值作为达成共识的阈值。
在两轮投票后，CIRCI 的诊断和管理方案获得通过，所有部分均达到 83.3%-100%的一致同意。该 CIRCI 方案为治疗难治性休克提供了一个临床方法的框架。建议所有疑似 CIRCI 的病例应立即开始每天接受 200mg 的氢化可的松治疗。对于不确定的随机皮质醇水平的患者，在 250μg ACTH 刺激试验后 60 分钟内，随机血清皮质醇<10 mcg/dL 或皮质醇增加<9 mcg/dL，则可明确诊断 CIRCI。
对液体复苏和血管加压素无反应的难治性休克的存在应引起临床怀疑存在 CIRCI，并应引发一系列管理策略。
