INTRODUCTION. At the moment, assessing adrenal dysfunction in patients in critical condition and ways to correct this function with hormone replacement therapy are extremely difficult. OBJECTIVE. Analysis of changes in the dynamics of adrenocorticotropic hormone (ACTH) and cortisol levels in blood plasma during extracorporeal membrane oxygenation (ECMO). MATERIALS AND METHODS. The prospective study was performed in intensive care unit (47 patients on ECMO). After connecting ECMO (D0), (D1-D3-D5-D7-D9), and until the completion of ECMO, assessment of cortisol and ACTH levels was carried out. RESULTS. The median level of cortisol in blood plasma was higher in the deceased patients on the third day (D3) (p = 0.05), D7 (p = 0.03); D13 (p = 0.05) and the last day of observation (p = 0.001), respectively. The level of ACTH in the blood of deceased patients was higher immediately on the day of ECMO initiation (D0) and on day 3 (D3) of observation: D0 (p = 0.018); D3 (p = 0.04), respectively. Analysis of the ROC curve showed that cortisol levels show a sensitivity of 71 % and a specificity of 89 % to an adverse outcome during ECMO. DISCUSSION. The life-saving ECMO technique, in critical conditions, is associated with a high risk of increasing of complications, including potentially lethal ones. Critical illness-related corticosteroid insufficiency (CIRCI) clinically manifests itself as inadequate adrenal activity, taking into account the augmentation of the disease severity. This activity is expressed in the form of a decrease in production and/or resistance to endogenous cortisol, as confirmed by the study. Consideration of CIRCI during the usage of ECMO reflects more objectively the violation of the pituitary-adrenal system. CONCLUSIONS. 1. CIRCI is detected in patients during ECMO. 2. High plasma cortisol levels are the predictor of an adverse outcome. 3. The level of ACTH in blood plasma is higher in patients with adverse outcomes. 4. High levels of cortisol in plasma are not a criterion for making the decision to initiate hydrocortisone therapy.

The aim of the study was to describe a clinical case of noninsulinoma pancreatogenous hypoglycemia (NIPH).Materials and methods. Patient R. 42 years old, woman, was admitted with complaints on spastic abdominal pain, heartburn, flatulence, bloating. The patient had a history of cramping pains in the upper abdomen, episodes of hypoglycemia up to once a day, periodically diarrhea with undigested food up to 3 times a day, and frequent weakness during last 9 years. In 2013, she was diagnosed with a neuroendocrine tumor of the pancreas, and therefore distal pancreatectomy was performed that year. According to histological and immuno-histochemical studies, foci of islet-cell hyperplasia (nesidioblastosis) were noted in the tail of the pancreas against the background of tissue fibrosis. Non-insulinoma pancreatogenous hypoglycemia of adults (NIPH) was diagnosed, enzyme replacement therapy and Octreotide-depo were prescribed. Relapses were noted twice. Two weeks before admission, the patient noted episodes of hypoglycemia. Upon admission, the patient had state of moderate severity, irregular stools up to 3–4 times a day. Antibacterial treatment was carried out, enzyme replacement therapy, octreotide was continued.Results. On the 7th day of hospitalization, the patient was stabilized: the level of glycemia was 4.5–4.9 mmol / l, the frequency and consistency of stool normalized. No data for decompensation of the disease has been received. The patient was discharged in a satisfactory condition.Conclusion. This clinical case demonstrates the influence of NIPH on the patient’s quality of life and the need for constant vigilance against the recurrence of hypoglycemic episodes, despite the treatment. This case can improve the awareness about this rare but important disease.

INTRODUCTION: The severity of the patient's condition that required ECMO and the changes observed in the pituitary — thyroid system (decreased T4 and T3 levels, low-normal or decreased TSH level) can be considered as a lack of body reserves due to the developed critical illness. OBJECTIVES: Study changes of TSH, T3, T4 levels during the ECMO procedure, during weaning/death on the ECMO. MATERIALS AND METHODS: The prospective observational study was performed in intensive care unit (47 patients on ECMO). After connecting ECMO (D0), (D1-D3-D5-D7-D9), and until the completion of ECMO, assessment of TSH, FT4, FT3 levels was carried out. OBJECTIVE: Analysis of changes in thyroid hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3) levels in blood plasma during ECMO, at ECMO weaning/death on ECMO. RESULTS: On the day of ECMO (D 0) and every second day, median FT4 levels were D0 (p = 0.03); D1 (p = 0.03); D3 (p = 0.05), D11 (p = 0.02) and last observation day (p = 0.009) between surviving and dying patients respectively. T3 level D5 (3.1–1.9; p = 0.002); D11 (3.7–2.5; p = 0.05), last day of follow-up (3.1–2; p = 0.001), respectively. On the last day of ECMO between the survived and non-survived patients there were the following: differences in TSH levels; negative correlation of lactate levels, SOFA score and FT3, TSH, FT4. The analysis of the ROC curve (low levels of FT3, FT4, TSH in plasma in patients on the last day of ECMO) indicates a prognostically unfavorable outcome. CONCLUSIONS: The moment of ECMO connection initiation is regarded as subacute phase critical illness. Along with a high level of plasma lactate and high score of SOFA scale, the level of decrease in FT3, FT4 and TSH in patients correlates with the lethal outcome. Low levels of TSH, FT4, and FT3 may be considered as a predictor of adverse outcome at the time of weaning/death on ECMO.

Currently, the assessment of adrenal dysfunction in critically ill patients and ways to correct adrenal dysfunction with hormone replacement therapy are extremely difficult. The results of the Cochrane meta-analysis “Corticosteroids for treating sepsis” showed that survival was higher among patients with respiratory distress syndrome and septic shock who received glucocorticoids (mainly hydrocortisone) for a long course and at low doses. These results are in very good agreement with the concept of critical illness-related corticosteroid insufficiency (CIRCI) development in the subacute and chronic stages of a critical condition and the need to prescribe glucocorticoid replacement therapy in this situation. International guidelines for the treatment of sepsis and septic shock for 2016 suggest avoiding the use of hydrocortisone in patients who developed sepsis. Only the development of septic shock, and the persisting instability of hemodynamics against the background of achieving normovolemia and high doses of vasopressors, are the indication for the use of hydrocortisone 200 mg intravenously. In 2021, revised guidelines approved the administration of hydrocortisone to patients in septic shock without waiting for an adequate fluid loading to be achieved. In contrast to these recommendations, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, in their recommendations for 2017, suggest for adrenal dysfunction caused by a critical condition in patients with severe community-acquired pneumonia and circulatory arrest the use of hydrocortisone in the early stages, before the development of multiple organ failure. The existing guidelines do not consider the use of hydrocortisone in critical conditions during extracorporeal membrane oxygenation (ECMO). The timing of hydrocortisone administration to critically ill patients requiring ECMO, and the duration of this therapy are currently a topical issue for intensive care specialists. To ensure the completeness of the list of references for compiling a systematic review in the databases MEDLINE, PubMed, MeSH, eLibrary.EN a search was performed for matches, by keywords, and phrases, the roots of keywords, taking into account possible word forms, by the first two hundred relevant links, in case there were so many links. The exclusion criterion was “the use of synthetic glucocorticoids”.

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