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Basic science and research
Critical illness-related corticosteroid insufficiency: latest pathophysiology and management guidelines
Fremita Chelsea Fredrick, Anish Kumar Reddy Meda, Bhupinder Singh, Rohit Jain
Acute Crit Care. 2024;39(3):331-340.   Published online August 30, 2024
DOI: https://doi.org/10.4266/acc.2024.00647
  • 5,921 View
  • 1,265 Download
AbstractAbstract PDF
Intensive care unit (ICU) admissions in the United States exceed 5.7 million annually, often leading to complications such as post-intensive care syndrome and high mortality rates. Among these challenges, critical illness-related corticosteroid insufficiency (CIRCI) requires emphasis due to its complex, multiple-cause pathophysiology and varied presentations. CIRCI, characterized by adrenal insufficiency during critical illness, presents in up to 30% of ICU patients and may manifest as an exaggerated inflammatory response. Factors such as dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, tissue corticosteroid resistance, and drug-induced suppression contribute to CIRCI. Diagnosis is a complex process, relying on a comprehensive assessment including clinical presentation, laboratory findings, and dynamic stimulatory testing. Treatment involves intensive medical care and exacting glucocorticoid therapy. Recent guidelines advocate for individualized approaches tailored to patient presentation and etiology. Understanding the pathophysiology and treatment of CIRCI is vital for clinicians managing critically ill patients and striving to improve outcomes. This research paper aims to explore the latest developments in the pathophysiology and management of CIRCI.
Original Articles
Immunology
Patterns of inflammatory immune responses in patients with septic shock receiving vitamin C, hydrocortisone, and thiamine: clustering analysis in Korea
Seung-Hun You, Oh Joo Kweon, Sun-Young Jung, Moon Seong Baek, Won-Young Kim
Acute Crit Care. 2023;38(3):286-297.   Published online August 21, 2023
DOI: https://doi.org/10.4266/acc.2023.00507
  • 2,813 View
  • 101 Download
  • 2 Web of Science
  • 2 Crossref
AbstractAbstract PDFSupplementary Material
Background
Sepsis is characterized by heterogeneous immune responses that may evolve during the course of illness. This study identified inflammatory immune responses in septic patients receiving vitamin C, hydrocortisone, and thiamine.
Methods
This was a single-center, post-hoc analysis of 95 patients with septic shock who received the vitamin C protocol. Blood samples were drawn on days 1–2, 3–4, and 6–8 after shock onset. Group-based multi-trajectory modeling was used to identify immune trajectory groups.
Results
The median age was 78 years (interquartile range, 70–84 years), and 56% were male. Clustering analysis identified group 1 (n=41), which was characterized by lower interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-10 levels, and these levels remained stationary or mildly increased until day 7. Conversely, group 2 (n=54) expressed initially higher IL-6, TNF-α, and IL-10 levels that decreased rapidly by day 4. There was a nonsignificant increase in lymphocyte count and a decrease in C-reactive protein level until day 7 in group 2. The intensive care unit mortality rate was significantly lower in group 2 (39.0% vs. 18.5%, P=0.03). Group 2 also had a significantly higher decrease in the mean (standard deviation) vasopressor dose (norepinephrine equivalent: –0.09±0.16 μg/kg/min vs. –0.23±0.31 μg/kg/min, P<0.001) and Sequential Organ Failure Assessment score (0±5 vs. –4±3, P=0.002) between days 1 and 4.
Conclusions
There may be different subphenotypes in septic patients receiving the vitamin C protocol.

Citations

Citations to this article as recorded by  
  • Micronutrients as therapy in critical illness
    Christian Stoppe, Ellen Dresen, Angelique de Man
    Current Opinion in Critical Care.2024; 30(2): 178.     CrossRef
  • Novel cortisol trajectory sub-phenotypes in sepsis
    Fei Leng, Zhunyong Gu, Simeng Pan, Shilong Lin, Xu Wang, Ming Zhong, Jieqiong Song
    Critical Care.2024;[Epub]     CrossRef
Basic science and research
Comparison of salivary and serum cortisol levels in mechanically ventilated patients and non-critically ill patients
Jung Hee Kim, Yoon Ji Kim, Sang-Min Lee, Jinwoo Lee
Acute Crit Care. 2020;35(3):149-155.   Published online August 31, 2020
DOI: https://doi.org/10.4266/acc.2020.00297
  • 6,049 View
  • 133 Download
  • 4 Web of Science
  • 3 Crossref
AbstractAbstract PDF
Background
Although the measuring free cortisol is ideal for assessment of hypothalamicpituitary-adrenal function, it is not routinely measured. Salivary cortisol correlates well with the biologically active free cortisol. Therefore, this study measured the morning basal as well as adrenocorticotropic hormone-stimulated salivary cortisol levels in mechanically ventilated patients and compared the results with non-critically ill patients.
Methods
We prospectively enrolled 49 mechanically ventilated patients and 120 patients from the outpatient clinic. Serum and saliva samples were collected between 8 AM and 10 AM. Salivary cortisol levels were measured using an enzyme immunoassay kit. The salivary samples were insufficient in 15 mechanically ventilated patients (30.6%), and these patients were excluded from the final analysis.
Results
Mechanically ventilated patients (n=34) were significantly older and had lower body mass index and serum albumin levels and higher serum creatinine levels than non-critically ill patients (n=120). After adjustment for these parameters, both basal and stimulated salivary and serum cortisol levels were higher in mechanically ventilated patients. The increase in cortisol was not significantly different between the two groups. Serum cortisol levels showed a positive correlation with salivary cortisol levels. Among mechanically ventilated patients, both basal serum and salivary cortisol levels were lower in survivors than in non-survivors.
Conclusions
Both basal total serum and salivary cortisol levels were elevated in mechanically ventilated patients and in non-survivors.

Citations

Citations to this article as recorded by  
  • Identity change and the transition to university: Implications for cortisol awakening response, psychological well‐being and academic performance
    Siobhán M. Griffin, Alžběta Lebedová, Tegan Cruwys, Grace McMahon, Aoife Marie Foran, Magdalena Skrodzka, Stephen Gallagher, Annie T. Ginty, Orla T. Muldoon
    Applied Psychology: Health and Well-Being.2025;[Epub]     CrossRef
  • Evaluating perioperative stresses in children by noninvasive modalities using salivary cortisol and autonomic reactivity
    Ayaka Adachi, Kentaro Fujiwara, Hiroko Watayo, Ailing Hu, Takuji Yamaguchi, Hisae Iida, Asuka Ishiyama, Masahiro Shimizu, Shuko Nojiri, Hiroyuki Koga, Hiroyuki Kobayashi, Geoffrey J. Lane, Atsuyuki Yamataka, Kazuto Suda
    Pediatric Surgery International.2024;[Epub]     CrossRef
  • Associations between chronic work stress and plasma chromogranin A/catestatin among healthy workers
    Xin Liu, Weimin Dang, Hui Liu, Yao Song, Ying Li, Weixian Xu
    Journal of Occupational Health.2022;[Epub]     CrossRef

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