Journal of Trauma & Treatment

Critical Illness Related Corticosteroid Insufficiency in Trauma - A Review

Abstract

Mark L. Walker

Critical Illness Related Corticosteroid Insufficiency is an intense inflammatory condition associated with steroid tissue resistance. Although traditionally felt to be uncommon, it is being increasingly recognized in severely stressed patients with prolonged intensive care unit stays. Over the last decade the spectrum of CIRCI in trauma has been better defined. Trauma patients with CNS (brain and or spinal cord) injury, burns or blunt multisystem injury are at particular risk. The diagnosis is best established using a random cortisol level combined with an Adrenocorticotrophic Hormone (ACTH) stimulation test. A low cortisol level and or a low response to the ACTH stimulation test in the setting of refractory shock makes the diagnosis. Stress dose hydrocortisone therapy is essential and improves outcome. CIRCI should be suspected in any elderly trauma victim with a prolonged ICU stay that exhibits shock. Drugs known to inhibit cortisol synthesis (like etomidate) are probably best avoided in this trauma subset. CIRCI in trauma has a bimodal distribution. The first peak occurs early (within 48 hours) after injury and is associated with shock and the attendant inflammatory response. The second peak occurs a week or more into the hospital course. This peak is usually associated with sepsis. Inflammatory cytokines (particularly IL-6) are elevated during both peaks but their exact role in establishing the diagnosis remains unclear. Physicians continue to search for the Eucorticoid state that achieves a balance between the inflammation initiated by the injury and the anti-inflammatory response anchored by endogenous steroid production. The administration of exogenous steroids to achieve this balance is an approach that seems to hold promise.