adrenal insufficiency in critical patients critical care medicine

A previously fit and well male in his early 40s, presented to the emergency department, hypotensive, bradycardic and hypothermic with reduced levels of consciousness after being found diaphoretic and unwell at his home. Despite fluid resuscitation with warmed saline, he remained hypotensive and required vasopressor support leading to intensive care admission. Initially, the patient was managed for suspected meningoencephalitis but was later found to have hypopituitarism leading to secondary hypothyroidism and adrenal insufficiency...

Opioid-induced adrenal insufficiency is a known side effect of chronic opioid use, but opioid-induced adrenal insufficiency related to chronic buprenorphine-naloxone therapy is less well-known. We present a case of a patient with opioid use disorder on chronic buprenorphine-naloxone therapy admitted with presumed septic shock and found to be in an adrenal crisis. The patient presented to our hospital with a shock-like presentation, requiring vasopressors, intubation, empiric glucocorticoids, and antibiotics...

In sepsis, dysregulation of the hypothalamic-pituitary-adrenal axis, alterations in cortisol metabolism, and tissue resistance to glucocorticoids can all result in relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI). The symptoms and signs of CIRCI during sepsis are nonspecific, generally including decreased mental status, unexplained fever, or hypotension refractory to fluids, and the requirement of vasopressor therapy to maintain adequate blood pressure. While we have been aware of this syndrome for over a decade, it remains a poorly understood condition, challenging to diagnose, and associated with significantly diverging practices among clinicians, particularly regarding the optimal dosing and duration of corticosteroid therapy...

BACKGROUND: Pheochromocytoma crisis (PCC) is a fatal disease characterized by hyper and/or hypotension, hyperthermia, and encephalopathy, and its diagnosis and treatment are challenging. CASE PRESENTATION: A 50-year-old woman presented with hypertension, and computed tomography showed an adrenal tumor. Fever, shock, and impaired consciousness were observed, and PCC was diagnosed clinically. Systolic blood pressure fluctuated from 40-220 mmHg within a few minutes, and circulatory agonists were adjusted accordingly...

OBJECTIVES: Rapid changes in glucocorticoid (GC) levels and adrenal insufficiency are related to the development of post-cardiac arrest (CA) syndrome. However, GC receptor (GR) expression changes have not been studied. Hence, this study aimed to investigate the association of early changes in GR expression and prognosis and immune response in patients who experienced CA. DESIGN: Prospective observational study. SETTING: Emergency department...

UNLABELLED: Hyponatremia is defined as serum sodium concentration less than 135meq/l. More severe symptoms are seen when serum sodium falls below 120 meq/l. Hyponatremia in ICU is a very common scenario. Treatment strategy is decided after thorough history taking and clinical examination. Judicious treatment is necessary as rapid correction and delayed correction both can lead to various neurological sequelae. This study was done on critically ill patients who had hyponatremia on the day of admission and clinical and aetiological profile was studied...

This case report describes new-onset adrenal insufficiency and adrenal shock in an 11-year-old male complaining of two weeks of malaise and weight loss. He was lethargic and pale in appearance. Work-up revealed hypoglycemia and hyponatremia without evidence for an infectious process. He was transported via a pediatric critical care transport team to a regional pediatric intensive care unit (PICU). He required intravenous fluids and vasopressors prior to arrival in the PICU. He had generalized weakness, and hyperpigmentation of his face and extremities...

PURPOSE: To test the benefits of Solumedrol treatment in sepsis patients with a blunted adrenocorticotropic hormone (ACTH)-cortisol response (delta <13 µg/dL) with regard to the number of days on ventilator, days on intravenous blood pressure support, length of time in an intensive care unit (ICU), 14-day mortality, and 28-day mortality. The trial was prospective, randomized, and double-blind. As part of a larger sepsis trial, 54 patients with sepsis had an intravenous ACTH stimulation test using 250 µg of ACTH, and serum cortisol was measured at times 0, 30, and 60 min...

About 3.4% of the hospitalized tubercular patients need admission to the intensive care unit (ICU). Patients requiring ICU admission had a poor prognosis and high mortality rate (60 vs 25%) as compared to other causes of severe pneumonia. The most common indication for tuberculosis-related ICU admission is acute respiratory failure due to pneumonia or acute respiratory distress syndrome (ARDS) (with or without miliary tuberculosis) followed by septic shock with multiple organ dysfunction, adrenal insufficiency, and neurological involvement, especially tubercular meningitis...

The current Coronavirus disease outbreak requires that physicians work in collaboration with other physicians especially in intensive care and emergency units. To fight against this new disease, whose pathogenesis, effects, and results have not been clearly demonstrated, especially in patients with the pre-existing chronic disease, requires special expertise and perspectives. Due to the need for dynamic glucocorticoid treatment at different stages of the disease in patients with adrenal insufficiency, the existence of reports indicating that "coronavirus disease 2019" also affects the adrenal reserve, and the use of glucocorticoids also in advanced stages in patients with Coronavirus disease require this issue to be emphasized with precision...

Background: Cortisol thresholds defining adrenal insufficiency (AI) in some cirrhosis-specific studies differ from those recommended by the SCCM/ESICM (Society of Critical Care Medicine/European Society of Intensive Care Medicine) guidelines, which may influence treatment decisions. Objective: To determine if stress-dose hydrocortisone (HC) improves outcomes in vasopressor-dependent patients meeting cirrhosis-specific criteria for AI. Methods: In this retrospective study, AI was defined using criteria from 2 studies in critically ill cirrhosis patients showing mortality reduction with HC (random cortisol <20 µg/dL, or if a standard-dose cosyntropin test was performed, baseline cortisol <15 µg/dL or delta cortisol <9 µg/dL if baseline = 15-34 µg/dL)...

OBJECTIVE: Although corticosteroid (CS) supplementation for pediatric septic shock (PSS) is recommended by American College of Critical Care Medicine sepsis guidelines, most data are based on adult trials. Standardized protocols for stimulation testing for adrenal insufficiency (AI) and CS treatment in children have been reported, but the current state of CS use and protocols have not been evaluated in pediatric intensive care units in the United States. We surveyed a group of pediatric intensivists to assess current approaches...

OBJECTIVES: To describe the controversies surrounding critical illness-related corticosteroid insufficiency (CIRCI) and the use of hydrocortisone in critically ill patients, and to present published diagnostic and therapeutic strategies in companion veterinary species. ETIOLOGY: Critical illness-related corticosteroid insufficiency may be due to hypothalamic-pituitary-adrenal (HPA) axis dysfunction, alterations in cortisol-plasma protein binding, target cell enzymatic changes, changes in glucocorticoid receptor (GR) function, or a combination of these or other factors present during critical illness...

Adequate adrenocortical function is essential for survival in critical illness. Most critically ill patients display elevated plasma cortisol concentrations, which reflects activation of the hypothalamic-pituitary-adrenal axis and is considered to be a homeostatic adaptation. However, many critically ill patients have 'relative' or 'functional' adrenal insufficiency, which is characterized by an inadequate production of cortisol in relation to an increased demand during periods of severe stress. Recently, the term 'critical illness-related corticosteroid insufficiency' (CIRCI) was coined...

OBJECTIVE: The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. DESIGN: Self-administered paper survey. POPULATION: Intensivists in academic hospitals with clinical trial expertise in critical illness. MEASUREMENTS: We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing...

Corticosteroids are used in the neonatal intensive care unit primarily to treat two conditions: bronchopulmonary dysplasia (BPD) and hypotension (cardiovascular insufficiency). Historically, high-dose dexamethasone was used for BPD, but its use was later associated with adverse neurodevelopmental outcomes and decreased substantially. Data from randomized controlled trials regarding efficacy and safety of lower-dose dexamethasone therapy are insufficient to recommend its use. Hydrocortisone may be an alternative to dexamethasone, but again data are insufficient to support use...

Patients with Addison's disease undergoing cardiac surgery are at risk of developing a crisis. There is no consensus on the preoperative and intraoperative management of this group of patients undergoing cardiac surgery so the recommendations for non-cardiac patients are often used. The consensus statement from the international task force of the American College of Critical Care medicine recommends 100 mg of intravenous hydrocortisone for patients with adrenal insufficiency in septic shock, but in patients undergoing surgery, especially with extracorporeal circulation, the dosage may even be higher...

BACKGROUND AND OBJECTIVE: Although there is controversy regarding the benefit of low-dose corticosteroid therapy in patients with septic shock, the Surviving Sepsis Campaign has advocated that low-dose intravenous hydrocortisone be used to treat adult septic shock patients. This study investigated the effect of the duration of a stress dose of hydrocortisone on survival of septic shock patients with relative adrenal insufficiency. METHODS: One hundred and thirty consecutive patients who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock were included in the study...

The precise definition of a severe asthmatic exacerbation is an issue that presents difficulties. The term 'status asthmaticus' relates severity to outcome and has been used to define a severe asthmatic exacerbation that does not respond to and/or perilously delays the repetitive or continuous administration of short-acting inhaled beta(2)-adrenergic receptor agonists (SABA) in the emergency setting. However, a number of limitations exist concerning the quantification of unresponsiveness. Therefore, the term 'acute severe asthma' is widely used, relating severity mostly to a combination of the presenting signs and symptoms and the severity of the cardiorespiratory abnormalities observed, although it is well known that presentation does not foretell outcome...

The stress response, which is triggered by a number of factors, including surgery, results in activation of the hypothalamic pituitary adrenal axis and subsequent release of cortisol from the adrenal glands. Critical illness-related corticosteroid insufficiency is an inadequate corticosteroid response relative to a patient's illness; patients with critical illness-related corticosteroid insufficiency have both insufficient circulating cortisol and impaired cellular use of glucocorticoids. Corticosteroids, such as hydrocortisone, have been cited to improve survival, oxygenation, duration of mechanical ventilation, and intensive care unit-free days in critically ill patients...