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Clinical review: corticotherapy in sepsis.

Prigent H, Maxime V, Annane D - Crit Care (2003)

Bottom Line: The use of glucocorticoids (corticotherapy) in severe sepsis is one of the main controversial issues in critical care medicine.The present review summarizes the basics of the physiological response of the hypothalamic-pituitary-adrenal axis to stress, including regulation of glucocorticoid synthesis, the cellular mechanisms of action of glucocorticoids, and how they influence metabolism, cardiovascular homeostasis and the immune system.The concepts of adrenal insufficiency and peripheral glucocorticoid resistance are developed, and the main experimental and clinical data that support the use of low-dose glucocorticoids in septic shock are discussed.

View Article: PubMed Central - PubMed

Affiliation: Service de Réanimation Médicale, Hôpital Raymond Poincaré, Garches, France.

ABSTRACT
The use of glucocorticoids (corticotherapy) in severe sepsis is one of the main controversial issues in critical care medicine. These agents were commonly used to treat sepsis until the end of the 1980s, when several randomized trials casted serious doubt on any benefit from high-dose glucocorticoids. Later, important progress in our understanding of the role played by the hypothalamic-pituitary-adrenal axis in the response to sepsis, and of the mechanisms of action of glucocorticoids led us to reconsider their use in septic shock. The present review summarizes the basics of the physiological response of the hypothalamic-pituitary-adrenal axis to stress, including regulation of glucocorticoid synthesis, the cellular mechanisms of action of glucocorticoids, and how they influence metabolism, cardiovascular homeostasis and the immune system. The concepts of adrenal insufficiency and peripheral glucocorticoid resistance are developed, and the main experimental and clinical data that support the use of low-dose glucocorticoids in septic shock are discussed. Finally, we propose a decision tree for diagnosis of adrenal insufficiency and institution of cortisol replacement therapy.

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Strategy for detection and treatment of adrenal failure during sepsis. ACTH, adrenocorticotrophic hormone.
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Figure 2: Strategy for detection and treatment of adrenal failure during sepsis. ACTH, adrenocorticotrophic hormone.

Mentions: Adrenal failure can contribute to haemodynamic instability and can perpetuate inflammation, and should therefore be sought out in patients presenting with severe sepsis. Haemodynamic instability, high dependency on catecholamines despite control of infection, and occurrence of hypoglycaemia or of hypereosinophilia should lead to suspicion of adrenal failure. Basal serum cortisol levels of 15 μg/dl or less indicate adrenal insufficiency [24,26]. When cortisol levels are greater than 15 μg/dl, an ACTH stimulation test is required to rule out adrenal insufficiency. An increment of 9 μg/dl or less strongly suggests adrenal failure. Finally, an increase in cortisol levels in excess of 9 μg/dl when the basal level is greater than 34 μg/dl suggests tissue resistance to glucocorticoid (Fig. 2).


Clinical review: corticotherapy in sepsis.

Prigent H, Maxime V, Annane D - Crit Care (2003)

Strategy for detection and treatment of adrenal failure during sepsis. ACTH, adrenocorticotrophic hormone.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC420022&req=5

Figure 2: Strategy for detection and treatment of adrenal failure during sepsis. ACTH, adrenocorticotrophic hormone.
Mentions: Adrenal failure can contribute to haemodynamic instability and can perpetuate inflammation, and should therefore be sought out in patients presenting with severe sepsis. Haemodynamic instability, high dependency on catecholamines despite control of infection, and occurrence of hypoglycaemia or of hypereosinophilia should lead to suspicion of adrenal failure. Basal serum cortisol levels of 15 μg/dl or less indicate adrenal insufficiency [24,26]. When cortisol levels are greater than 15 μg/dl, an ACTH stimulation test is required to rule out adrenal insufficiency. An increment of 9 μg/dl or less strongly suggests adrenal failure. Finally, an increase in cortisol levels in excess of 9 μg/dl when the basal level is greater than 34 μg/dl suggests tissue resistance to glucocorticoid (Fig. 2).

Bottom Line: The use of glucocorticoids (corticotherapy) in severe sepsis is one of the main controversial issues in critical care medicine.The present review summarizes the basics of the physiological response of the hypothalamic-pituitary-adrenal axis to stress, including regulation of glucocorticoid synthesis, the cellular mechanisms of action of glucocorticoids, and how they influence metabolism, cardiovascular homeostasis and the immune system.The concepts of adrenal insufficiency and peripheral glucocorticoid resistance are developed, and the main experimental and clinical data that support the use of low-dose glucocorticoids in septic shock are discussed.

View Article: PubMed Central - PubMed

Affiliation: Service de Réanimation Médicale, Hôpital Raymond Poincaré, Garches, France.

ABSTRACT
The use of glucocorticoids (corticotherapy) in severe sepsis is one of the main controversial issues in critical care medicine. These agents were commonly used to treat sepsis until the end of the 1980s, when several randomized trials casted serious doubt on any benefit from high-dose glucocorticoids. Later, important progress in our understanding of the role played by the hypothalamic-pituitary-adrenal axis in the response to sepsis, and of the mechanisms of action of glucocorticoids led us to reconsider their use in septic shock. The present review summarizes the basics of the physiological response of the hypothalamic-pituitary-adrenal axis to stress, including regulation of glucocorticoid synthesis, the cellular mechanisms of action of glucocorticoids, and how they influence metabolism, cardiovascular homeostasis and the immune system. The concepts of adrenal insufficiency and peripheral glucocorticoid resistance are developed, and the main experimental and clinical data that support the use of low-dose glucocorticoids in septic shock are discussed. Finally, we propose a decision tree for diagnosis of adrenal insufficiency and institution of cortisol replacement therapy.

Show MeSH
Related in: MedlinePlus