Critical Illness-Related Corticosteroid Insufficiency (CIRCI) among patients with refractory shock at a tertiary hospital: A look into clinical practices and patient outcomes

ABSTRACT

@#<p style="text-align justify;"><strong>Introduction.</strong> A significant number of critically ill patients, as high as 60% among patients with septic shock, suffer from critical illness-related corticosteroid insufficiency (CIRCI), which refers to an inadequate corticosteroid response to the level of stress.</p><p style="text-align justify;"><strong>Objectives.</strong> This study aimed to determine the strategies employed in managing patients with critical illness-related corticosteroid insufficiency and the outcomes of these patients at a tertiary hospital.</p><p style="text-align justify;"><strong>Methods.</strong> This was a single-center, mixed-methods study which consisted of a review of charts of patients 19 years old and above admitted for shock or developed refractory hypotension from January 2017-December 2019, and key informant interviews and focus group discussion among clinicians who have experience in managing CIRCI.</p><p style="text-align justify;"><strong>Results.</strong> A total number of 362 patient charts reviewed showed a relatively low rate of initiation of corticosteroids for patients with refractory shock, at just 28.57% of the entire population. After corticosteroids were initiated, patients were in shock for a median of just one day and the median blood pressure improved to 100/60 mm Hg. In this cohort, patients who were started on steroids had more severe illness, as measured by the Mortality Probability Model (MPM) score, which had a median of 43.65% for the group on steroids and just 25.0% for the non-steroid group (p ? 0.0001). Patients who were started on steroids had a statistically significant longer median days on a ventilator, 5 days vs. 3 days for the non-steroid group (p = 0.0297); longer median length of intensive care unit (ICU) stay, 8 days vs. 5 days for the non-steroid group (p = 0.0410), and a higher morbidity and mortality rate. The need for steroids, the presence of septic shock, and a higher MPM score were significant predictors of mortality.</p><p style="text-align justify;">Discussions among clinicians revealed significant variability in practices in the management of CIRCI.</p><p style="text-align justify;"><strong>Conclusion.</strong> The presence of clinical features of CIRCI is a poor prognostic factor. Timely recognition, work-up, and interventions to address CIRCI are paramount in critical care.</p>