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CRITICAL CARE

An Update on the Diagnosis of Adrenal Insufficiency and the Use of Corticotherapy in Critical Illness

Clinical Assistant Professor of Pharmacy, Ernest Mario School of Pharmacy—Rutgers, State University of New Jersey, Piscataway, NJ; Clinical Pharmacist, Hackensack University Medical Center, Hackensack, NJ

Gilles L Fraser, PharmD FCCM

Professor of Medicine, College of Medicine, University of Vermont, Burlington, VT; Clinical Pharmacist in Critical Care, Maine Medical Center, Portland, ME

Reprints: Dr. Thomas, Hackensack University Medical Center, 30 Prospect Ave., Hackensack, NJ 07601, fax 201/996-4910, zachariah.thomas{at}gmail.com

OBJECTIVE: To examine recent literature regarding corticotherapy in critically ill patients suffering from sepsis, acute respiratory distress syndrome (ARDS), and severe community-acquired pneumonia (SCAP).

DATA SOURCES: Literature was identified through MEDLINE (1966-April 2007) using combinations of the key words hydrocortisone, adrenal insufficiency, acute respiratory distress syndrome, pneumonia, sepsis, and cortisol. Bibliographies of relevant articles were reviewed for additional citations. Presentations at recent critical care meetings were also incorporated.

STUDY SELECTION AND DATA EXTRACTION: Articles were chosen based upon their relevance to the topics covered.

DATA SYNTHESIS: Earlier studies using high-dose corticotherapy in the intensive care unit have shown treatment to be ineffective. Recent studies using extended courses of low-to-moderate doses of steroids have found favorable results; however, these results must be interpreted with caution due to limitations in the data. One trial of steroids in septic shock found a survival benefit in patients who failed to increase their baseline cortisol by greater than 9 µg/dL in response to adrenocorticotropic hormone, but these results were not reproduced in a subsequent Phase 3 trial. Recently, inaccuracies in measuring cortisol have been identified, making interpretation of cortisol concentrations difficult. A large-scale study failed to confirm a previously reported mortality benefit of corticotherapy in late ARDS, but preliminary data suggest a role for steroid treatment in early ARDS. Finally, a pilot study has found that hydrocortisone lowers morbidity and mortality in SCAP.

CONCLUSIONS: Corticotherapy may be beneficial to some patients with sepsis. The decision to administer steroids in sepsis cannot be based on biochemical markers of adrenal function; rather, treatment should be considered in septic patients with vasopressor refractory hypotension. Although preliminary evidence suggests a role for steroids in early ARDS and SCAP, there are not enough data to suggest routine administration of steroids in these conditions. Additional studies are needed to assess corticotherapy in the critically ill.

Key Words: acute respiratory distress syndrome, adrenal insufficiency, cortisol, hydrocortisone, pneumonia, sepsis

Published Online, August 14, 2007. www.theannals.com, DOI 10.1345/aph.1K082

THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-07-022-H01