Q: The reason behind adrenal insufficiency in critical illness is? (select one)
A) Subnormal corticosteroid production
B) Increased cellular steroid utilization
During critical illnesses such as septic shock, the reason behind adrenal insufficiency is subnormal corticosteroid production. The hypothalamic-pituitary-adrenal axis stays intact. This is referred to as functional or relative adrenal insufficiency. Another designated term is "critical illness-related corticosteroid insufficiency (CIRCI)." The administration of steroids during pressor-resistant shock despite adequate fluid resuscitation is to balance the altered hypothalamic-pituitary-adrenal (HPA) axis.
Despite the intact structure of the HPA axis, there are various reasons which lead to adrenal insufficiency. This includes HPA activation which actually increases the circulating cortisol, HPA impairment which causes adrenocortical hyporesponsiveness, and glucocorticoid resistance.
Unfortunately, clinicians so far failed to reach any consensus definition of CIRCI, and management mostly depends on clinician's judgment and few guidelines.
1. Boonen E, Vervenne H, Meersseman P, et al. Reduced cortisol metabolism during critical illness. N Engl J Med 2013; 368:1477. Malerba G, Romano-Girard F, Cravoisy A, et al. Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Intensive Care Med 2005; 31:388.
2. Cohen J, Pretorius CJ, Ungerer JP, et al. Glucocorticoid Sensitivity Is Highly Variable in Critically Ill Patients With Septic Shock and Is Associated With Disease Severity. Crit Care Med 2016; 44:1034.
3. Burry LD, Wax RS. Role of corticosteroids in septic shock. Ann Pharmacother 2004; 38:464.
4. Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med 2017; 43:1751.
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