Critical Illness-Related Corticosteroid Insufficiency in Children

Abstract

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. CIRCI occurs as a result of a decrease in adrenal steroid production or tissue resistance to glucocorticoids. An international task force of the American College of Critical Care Medicine issued recommendations for the diagnosis and management of this condition in adult patients. We review the prevalence, diagnosis, and therapeutic approach to adrenal insufficiency in critically ill children. We found a lack of consensus within the pediatric field as to the optimal approach to CIRCI, and call for an international task force to establish unified guidelines.

Assessing endocrine and immune parameters in human immunodeficiency virus-infected patients before and after the immune reconstitution inflammatory syndrome

“…It has been proposed that an exacerbated proinflammatory response could result from the suppression of the HPA axis and of adrenal failure or reflect glucocorticoid tissue resistance as well (31,32). This clinical disorder is known as critical illness-related corticosteroid insufficiency resulting from an inadequate corticosteroid production or action for such severe disease (32,33). In agreement with the previous idea, patients with adrenal insufficiency could present an altered regulation of the immune system, which has been linked to IRIS (34).…”

“…Previous reports have suggested an intra-adrenal shift from DHEAS towards the cortisol production during critical illness (28)(29)(30), as could be the case of HIV infected patients who suffered IRIS. It has been proposed that an exacerbated proinflammatory response could result from the suppression of the HPA axis and of adrenal failure or reflect glucocorticoid tissue resistance as well (31,32). This clinical disorder is known as critical illness-related corticosteroid insufficiency resulting from an inadequate corticosteroid production or action for such severe disease (32,33).…”

Endocrinologic Diseases in Pediatric Cardiac Intensive Care

“…It is thought to occur as a result of a decrease in adrenal steroid production due to dysfunction at any point in the hypothalamus pituitary adrenal (HPA) axis or due to tissue resistance to glucocorticoids (40). …”

“…The response is calculated by determining the difference between the baseline cortisol concentration and the highest concentration measured at 30 or 60 minutes. Many threshold concentrations have been proposed to define what is an “appropriate” response (40, 41). Recent studies have shown that high cortisol levels during critical illness are a consequence of decreased metabolism and clearance of cortisol rather than increased production (42, 43).…”

Adrenal Dysfunction

“…Among critically ill children and adolescents, a low incremental cortisol response to ACTH does not predict mortality [28]. There is still much controversy regarding how to best look for adrenal insufficiency in hospitalized patients, as well as whether and when to treat [29]. Glucocorticoid treatment of shock remains controversial, as most of the published trials have methodologic flaws, varied endpoints, and conflicting outcomes [30].…”