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Objectives 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. Methodology 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. Results 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. Conclusion 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.

RATIONALE Sepsis is the leading cause of mortality among medical patients in the Philippine General Hospital (PGH). A previous study illustrated variations in sepsis management. The Department of Medicine developed a sepsis pathway based on the Surviving Sepsis Campaign bundles to standardize care and improve outcomes. We determined the coverage and compliance with the pathway, the barriers to compliance and sepsis-related mortality. METHODS This was a single-center mixed methods study on the pilot implementation of the sepsis pathway (April 8 to July 7, 2019) in the medical service areas, i.e. emergency department (ED), medical wards and medical intensive care unit (MICU), of a tertiary level teaching hospital. We tracked all medicine charity admissions with infections to determine coverage. Compliance and patient outcomes were assessed through chart reviews. Focus group discussions and interviews were done to identify barriers to implementing the sepsis bundle. RESULTS Among 296 admissions with infections (49% female, mean age 51.4 years), there were 422 patient-days eligible for pathway coverage but only 199 patient-days (47.16%) were covered. The ED had the highest coverage rate. Overall mortality rate among the admissions was at 39.2%. Among septic patients who were covered, 40% died. Missed cases were associated with increased odds of in-hospital death (adjusted odds ratio [aOR]: 1.42, 95% CI: 1.13 to 1.88) on multivariate analysis. Compliance with recommended diagnostics was high except for lactate and bilirubin. Blood cultures were sent 98% of the time. Only 35% of patients received antibiotics by one hour after activation. Fluids recorded over 6 hours were inadequate (mean 4.77 mL/kg, standard deviation: 2.82 mL/kg). Of 73 patients with hypotension needing fluid resuscitation, only 12 had blood pressure documented 30 minutes post-activation. Stakeholders identified inadequate human and physical resources, hospital policy changes and pathway form construction as barriers to compliance. Fellows, nurses, and students reported lack of orientation on their roles.

Objectives. Among critically ill patients, there is usually impairment of the hypothalamic-pituitary-adrenal axis, leading to a condition known as critical illness-related corticosteroid insufficiency (CIRCI). This investigation aims to determine the incidence of and characterize CIRCI among patients with COVID-19 as well as to analyze the outcomes of these critically ill patients.Methodology. This is a single-center, retrospective cohort study that investigated the occurrence of CIRCI among critically ill patients infected with COVID-19.Results. In this cohort, there were 145 COVID-19-positive patients with refractory shock, which reflects that 22.94% of the COVID-19 admissions have probable CIRCI.Patients who were given corticosteroids were found to have statistically significant longer median days on a ventilator (p=0.001). However, those on the corticosteroid arm were at higher risk of morbidity and mortality and a greater proportion had organ dysfunction. Multivariable logistic regression analysis revealed that SOFA score was a significant predictor of mortality in CIRCI (p=0.013).Conclusion. CIRCI has a unique presentation among patients with COVID-19 because of the presence of a high level of inflammation in this life-threatening infection. It is possibly a harbinger of a markedly increased risk of mortality in these patients.