Sepsis and Adrenal Insufficiency

Abstract

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. The existing literature on corticosteroid use in patients with sepsis and septic shock is vast with dozens of randomized controlled trials conducted across the past 4 decades. These studies have universally demonstrated reduced duration of shock, though the effects of corticosteroids on mortality have been inconsistent, and their use has been associated with adverse effects including hyperglycemia, neuromuscular weakness, and an increased risk of infection. In this article, we aim to provide a thorough, evidence-based, and practical review of the current recommendations for the diagnosis and management of patients with sepsis who develop CIRCI, explore the controversies surrounding this topic, and highlight what lies on the horizon as new evidence continues to shape our practice.

Effect of cortisol and glycosylated-hemoglobin levels on mortality in intensive care unit

“…It has also been reported that cortisol values are higher in patients with lung insufficiency and sepsis than in those with gastrointestinal bleeding. 7 Furthermore, diseases that prompt rapid admission to the ICU may lead to high cortisol values, which could independently predict patient outcomes. 8 - 10 De Castro et al 8 shown that basal cortisol levels, measured upon admission of patients with septic shock and severe sepsis to the ICU, are the best prognostic factor for 28-day mortality.…”

Do We Need to Administer Fludrocortisone in Addition to Hydrocortisone in Adult Patients With Septic Shock? An Updated Systematic Review With Bayesian Network Meta-Analysis of Randomized Controlled Trials and an Observational Study With Target Trial Emulation*

“…Growing concerns among intensivists are centered around critical-illness-related corticosteroid and mineralocorticoid deficiencies ( 3 , 4 ). The International Guideline of Surviving Sepsis Campaign conditionally recommended administration of IV hydrocortisone at a typical dose of 200 mg/d to adult patients with septic shock necessitating vasopressor support ( 5 ).…”