Guidelines for the diagnosis and management of critical illness related corticosteroid insufficiency (CIRCI) in critically ill adult and pediatric patients (Part I): Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM): 2017

OBJECTIVE: To provide an update to the 2008 consensus statements for the diagnosis and management of critical illness related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. PARTICIPANTS: A multi-specialty task force of 16 international experts in critical care medicine, endocrinology, guideline methods, and members of the Society of Critical Care Medicine and 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 literature from an updated systematic review incorporating relevant studies from 2008 to 2017 and 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 that included the individual study design, risk of bias, consistency of the results, and the directness and precision of the evidence. Recommendation approval required agreement from at least 80% of the task force members. RESULTS: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI although the delta cortisol (change in baseline cortisol at 60 minutes of < 9 mcg/dL) after cosyntropin (250 mcg) administration and a random plasma cortisol of < 10 mcg/dL may be used most commonly 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 intravenous (IV) hydrocortisone <400 mg/day for at >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 against 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). CONCLUSIONS: 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.