Guideline sources The following summarized guidelines for the evaluation and management of critical illness-related corticosteroid insufficiency are prepared by our editorial team based on guidelines from the Surviving Sepsis Campaign (SSC 2021), the Infectious Diseases Society of America (IDSA/ATS 2019), the European Society of Intensive Care Medicine (ESICM/SCCM 2018; 2017), the British Medical Journal (BMJ 2018), and the European Association for the Study of the Liver (EASL 2018). 1 2 3 4 5 6 Guidelines 1. Diagnostic investigations Adrenal function testing: insufficient evidence to recommend whether to use delta cortisol (change in baseline cortisol at 60 mins of < 9 g/dL) after cosyntropin (250 g) administration or random plasma cortisol of < 10 g/dL for the diagnosis of critical illness-related corticosteroid insufficiency. Show 5 more 2. Medical management Corticosteroid administration, sepsis: https://web.pathway.md/diseases/recVKk6xYRcuppVax 1/3 6/23/23, 3:36 AM Critical illness-related corticosteroid insufficiency Pathway As per SSC 2021 guidelines, consider administering IV corticosteroids in adult patients with septic shock and an ongoing requirement for vasopressor therapy. E As per BMJ 2018 guidelines, consider administerings corticosteroids in adult and pediatric patients with sepsis, with or without shock. C As per ESICM/SCCM 2017 guidelines, avoid administering corticosteroids in adult patients with sepsis without shock. D Show 2 more Corticosteroid administration, pneumonia: As per ATS/IDSA 2019 guidelines: Do not administer corticosteroids routinely in adult patients with non-severe community- acquired pneumonia. D Avoid administering corticosteroids routinely in adult patients with severe community-acquired pneumonia D or severe influenza pneumonia. D As per ESICM/SCCM 2018 guidelines: Consider administering corticosteroids (IV hydrocortisone 400 mg/day, or equivalent) for 5-7 days in hospitalized patients with community-acquired pneumonia. C Avoid administering corticosteroids in adult patients with influenza. D Corticosteroid administration (ARDS): consider administering corticosteroids in patients with early moderate-to-severe ARDS (PaO /FiO of < 200 and within 14 days of onset). C Corticosteroid administration (meningitis): administer corticosteroids in patients with bacterial meningitis. B Corticosteroid administration (major trauma): avoid administering corticosteroids in patients with major trauma. D Corticosteroid administration (cardiopulmonary bypass surgery): consider administering corticosteroids in patients undergoing cardiopulmonary bypass surgery. C Corticosteroid administration (cardiac arrest): consider administering corticosteroids in patients with cardiac arrest. C 3. Specific circumstances Patients with liver cirrhosis: diagnose relative adrenal insufficiency based on a delta serum total cortisol of < 248 nmol/L (9 g/dL) after 250 g corticotropin injection or a random total cortisol of < 276 nmol/L (< 10 g/dL). B Show 2 more References https://web.pathway.md/diseases/recVKk6xYRcuppVax 2/3 6/23/23, 3:36 AM Critical illness-related corticosteroid insufficiency Pathway 1. Stephen M Pastores, Djillali Annane, Bram Rochwerg et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency CIRCI in critically ill patients Part II Society of Critical Care Medicine SCCM and European Society of Intensive Care Medicine ESICM 2017. Intensive Care Med. 2018 Apr;44 4 474 477. Open 2. Lamontagne F, Rochwerg B, Lytvyn L et al. Corticosteroid therapy for sepsis: a clinical practice guideline. BMJ. 2018 Aug 10;362:k3284. Open 3. Metlay JP, Waterer GW, Long AC et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200 7):e45-e67. Open 4. Djillali Annane, Stephen M Pastores, Bram Rochwerg 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. Crit Care Med. 2017 Dec;45 12 2078 2088. Open 5. Laura Evans, Andrew Rhodes, Waleed Alhazzani et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47 11 1181 1247. Open 6. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open https://web.pathway.md/diseases/recVKk6xYRcuppVax 3/3