Recommendations for the diagnosis and management of corticosteroid insufficiency

分類:熱門文章 建立於 2008-06-01, 週日 最近更新於 2012-11-10, 週六 作者 林鎮均

這一期的Critical care medicine有一篇關於重症病患的adrenal insufficiency 的consensus statements,共有以下12個recommendations:
  1. Recommendation 1: Dysfunction of the HPA axis in critical illness is best described by the term critical illness–related corticosteroid insufficiency (CIRCI). 
  2. Recommendation 2: The terms absolute or relative adrenal insufficiency are best avoided in the context of critical illness.
  3. Recommendation 3: At this time, adrenal insufficiency in critical illness is best diagnosed by a delta cortisol (after 250 µg cosyntropin) of <9 µg/dL or a random total cortisol of <10 µg/dL. Strength of Recommendation: 2B 
  4. Recommendation 4: The use of free cortisol measurements cannot be recommended for routine use at this time. Although the free cortisol assay has advantages over the total serum cortisol, this test is not readily available. Furthermore, the normal range of the free cortisol in critically ill patients is currently unclear. Strength of Recommendation: 2B 
  5. Recommendation 5: The ACTH stimulation test should not be used to identify those patients with septic shock or ARDS who should receive GCs. Strength of Recommendation: 2B
  6. Recommendation 6: Hydrocortisone should be considered in the management strategy of patients with septic shock, particularly those patients who have responded poorly to fluid resuscitation and vasopressor agents. Strength of Recommendations: 2B
  7. Recommendation 7: Moderate-dose GC should be considered in the management strategy of patients with early severe ARDS (Pao2/Fio2 of <200) and before day 14 in patients with unresolving ARDS. The role of GC treatment in acute lung injury and less severe ARDS (Pao2/Fio2 of >200) is less clear. Strength of Recommendations: 2B
  8. Recommendation 8: In patients with septic shock, intravenous hydrocortisone should be given in a dose of 200 mg/day in four divided doses or as a bolus of 100 mg followed by a continuous infusion at 10 mg/hr (240 mg/day). The optimal initial dosing regimen in patients with early severe ARDS is 1 mg/kg/day methylprednisolone as a continuous infusion. Strength of Recommendation: 1B
  9. Recommendation 9: The optimal duration of GC treatment in patients with septic shock and early ARDS is unclear. However, based on published studies and pathophysiological data, patients with septic shock should be treated for >=7 days before tapering, assuming that there is no recurrence of signs of sepsis or shock. Patients with early ARDS should be treated for >=14 days before tapering. Strength of Recommendation: 2B
  10. Recommendation 10: GC treatment should be tapered slowly and not stopped abruptly. Strength of Recommendation: 2B
  11. Recommendation 11: Treatment with fludrocortisone (50 µg orally once daily) is considered optional. Strength of Recommendation: 2B
  12. Recommendation 12: Dexamethasone is not recommended for the treatment of septic shock or ARDS. Strength of Recommendation: 1B