Vasodilatory shock in severe acute pancreatitis without sepsis: is there any place for hydrocortisone treatment?

Updates in the Management of Perioperative Vasoplegic Syndrome

Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.

Corticosteroid treatment for acute/acute-on-chronic experimental and naturally occurring pancreatitis in several species: a scoping review to inform possible use in dogs

Acute pancreatitis in dogs is a prevalent disease characterised by mild to severe inflammation. Treatment with anti-inflammatory corticosteroids has been widely debated but is not generally recommended in veterinary medicine. The objective of the present study was to present current evidence on the effect of corticosteroid treatment for acute/acute-on-chronic pancreatitis across species. These findings were then used to evaluate if and how corticosteroid treatment could influence disease outcome in canine acute/acute-on-chronic pancreatitis. A scoping review was performed by searching the Agricola, CAB Abstracts, MEDLINE and Embase databases to identify relevant articles published before June 24, 2021. The inclusion criteria were English language, original research published in a peer-reviewed journal, and investigation of corticosteroid treatment effects on acute/acute-on-chronic pancreatitis by the outcome parameters clinical score, circulating CRP level, hospitalisation duration, mortality and pancreas histopathology. Research on any species was considered. Studies were rated based on the level of evidence, and methodological quality was evaluated based on similarity between groups at baseline, risk of bias and study group size. The reporting method was based on the PRISMA extension for scoping reviews. One thousand nine hundred fifty-four studies were identified, and 31 met the inclusion criteria. Five were canine studies, with 4 investigating experimentally induced pancreatitis; 5 were human clinical studies; and 21 were rodent studies of experimentally induced pancreatitis. The level of evidence ranged between randomised controlled trials and case series, the estimated risk of bias ranged from low to high, and the sample sizes ranged from very small to moderate. Evidence indicates that adding corticosteroid to symptomatic treatment of acute/acute-on-chronic canine pancreatitis could have a positive influence on disease outcome. However, the analysed evidence was based on several species, including both naturally occurring and experimentally induced pancreatitis; thus, the authors suggest that large randomised controlled studies should be performed in dogs with spontaneously occurring acute/acute-on-chronic pancreatitis to further elucidate a potential benefit of corticosteroid treatment.

Definitions and pathophysiology of vasoplegic shock

Vasoplegia is the syndrome of pathological low systemic vascular resistance, the dominant clinical feature of which is reduced blood pressure in the presence of a normal or raised cardiac output. The vasoplegic syndrome is encountered in many clinical scenarios, including septic shock, post-cardiac bypass and after surgery, burns and trauma, but despite this, uniform clinical definitions are lacking, which renders translational research in this area challenging. We discuss the role of vasoplegia in these contexts and the criteria that are used to describe it are discussed. Intrinsic processes which may drive vasoplegia, such as nitric oxide, prostanoids, endothelin-1, hydrogen sulphide and reactive oxygen species production, are reviewed and potential for therapeutic intervention explored. Extrinsic drivers, including those mediated by glucocorticoid, catecholamine and vasopressin responsiveness of the blood vessels, are also discussed. The optimum balance between maintaining adequate systemic vascular resistance against the potentially deleterious effects of treatment with catecholamines is as yet unclear, but development of novel vasoactive agents may facilitate greater understanding of the role of the differing pathways in the development of vasoplegia. In turn, this may provide insights into the best way to care for patients with this common, multifactorial condition.

The adrenocorticotropic hormone-induced cortisol response in acute pancreatitis

The evidence that severe acute pancreatitis can result in critical illness-related corticosteroid insufficiency following impaired adrenal secretion is accumulating. The study by Peng and coworkers in Critical Care certainly contributes to that idea, even though the question whether relative adrenal insufficiency should prompt for treatment by substitution doses of corticosteroids remains unresolved. The study is discussed in terms of the risk factors, circumstances and significance of impaired corticosteroid secretion by adrenals in severe acute pancreatitis.

Critical illness-related corticosteroid insufficiency in patients with severe acute biliary pancreatitis: a prospective cohort study

Introduction

Gallstones are the most common cause of acute pancreatitis worldwide. Patients with severe acute biliary pancreatitis (SABP) constitute a subgroup of severe acute pancreatitis (SAP) patients in whom systemic inflammation may be triggered and perpetuated by different mechanisms. The aim of this prospective investigation was to examine the adrenal response to corticotropin and the relationship between adrenal function and outcome in patients with SABP.

Methods

Thirty-two patients with SABP were enrolled in this study. A short corticotropin (250 μg) stimulation test (SST) was performed within the first 24 hours of admission to the ICU. Critical illness related corticosteroid insufficiency (CIRCI) was defined as follows: baseline value less than 10 μg/dL, or cortisol response less than 9 μg/dL.

Results

CIRCI occurred in 34.4% of patients. The patients with CIRCI were more severely ill as evidenced by higher APACHE II and SOFA scores and numbers of organ system dysfunction on the day of SST. The in-hospital mortality for the entire group was 21.9%. The CIRCI group had a higher hospital mortality rate compared to those with normal adrenal function (45.5% vs. 9.5%, P = 0.032). The hospital survivors had a higher cortisol response to corticotropin (17.4 (8.3–27.1) vs. 7.2 (1.7–12) μg/dL, P = 0.019). The cortisol response to corticotropin inversely correlated with SOFA score and the number of organ dysfunction on the day of SST. The rates of pancreatic necrosis and bacteremia were significantly higher in the CIRCI group (100% vs 42.9%, P = 0.002; 81.8% vs 23.8%, P = 0.003, respectively).

Conclusions

CIRCI is common in patients with SABP. It is associated with bacteremia, multiple organ dysfunction and increased mortality.

Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine

OBJECTIVE

To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients.

PARTICIPANTS

A multidisciplinary, multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. In addition, international experts in endocrinology were invited to participate.

DESIGN/METHODS

The task force members reviewed published literature and provided expert opinion from which the consensus was derived. The consensus statements were developed using a modified Delphi methodology. The strength of each recommendation was quantified using the Modified GRADE system, which classifies recommendations as strong (grade 1) or weak (grade 2) and the quality of evidence as high (grade A), moderate (grade B), or low (grade C) based on factors that include the study design, the consistency of the results, and the directness of the evidence.

RESULTS

The task force coined the term critical illness-related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness. Critical illness-related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted proinflammatory response. Critical illness-related corticosteroid insufficiency should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents, particularly in the setting of sepsis. At this time, the diagnosis of tissue corticosteroid resistance remains problematic. Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of < 9 microg/dL after adrenocorticotrophic hormone (250 microg) administration or a random total cortisol of < 10 microg/dL. The benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (PaO2/FiO2 of < 200 and within 14 days of onset). The adrenocorticotrophic hormone stimulation test should not be used to identify those patients with septic shock or acute respiratory distress syndrome who should receive glucocorticoids. Hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day (10 mg/hr) for > or = 7 days is recommended for septic shock. Methylprednisolone in a dose of 1 mg x kg(-1) x day(-1) for > or = 14 days is recommended in patients with severe early acute respiratory distress syndrome. Glucocorticoids should be weaned and not stopped abruptly. Reinstitution of treatment should be considered with recurrence of signs of sepsis, hypotension, or worsening oxygenation. Dexamethasone is not recommended to treat critical illness-related corticosteroid insufficiency. The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation.

CONCLUSION

Evidence-linked consensus statements with regard to the diagnosis and management of corticosteroid deficiency in critically ill patients have been developed by a multidisciplinary, multispecialty task force.

Current pharmacotherapeutic recommendations for acute pancreatitis

Disease severity in patients with acute pancreatitis varies from mild disease with minimal morbidity to severe disease in which a whole spectrum of local and systemic complications may occur. Infectious complications frequently arise, and pancreatic necrosis in particular is an important risk factor for mortality. Several strategies have been investigated to stop the progression of organ dysfunction, targeting different steps in the pathogenesis, but none of these have proved beneficial. In recent years, the widespread use of prophylactic antibiotics has also been in question, as one blinded study could not demonstrate an advantage. Better risk stratification methods should improve the design of future trials, so that only patients with a high probability of complications can be studied.

Mechanisms and clinical consequences of critical illness associated adrenal insufficiency

PURPOSE OF REVIEW

Adrenal insufficiency is being diagnosed with increasing frequency in critically ill patients. There exists, however, much controversy in the literature as to the nature of this entity, including its pathophysiology, epidemiology, diagnosis and treatment. The review summarizes our current understanding of the causes and consequences of adrenal insufficiency in critically ill patients.

RELEVANT FINDINGS

Activation of the hypothalamic-pituitary-adrenal axis with the production of cortisol is a fundamental component of the stress response and is essential for survival of the host. Dysfunction of the hypothalamic-pituitary-adrenal axis with decreased glucocorticoid activity is being increasingly recognized in critically ill patients, particularly those with sepsis. This condition is best referred to as 'critical illness-related corticosteroid insufficiency'. Critical illness-related corticosteroid insufficiency may occur due to dysfunction at any point in the hypothalamic-pituitary-adrenal axis including tissue glucocorticoid resistance. Critical illness-related corticosteroid insufficiency leads to an exaggerated proinflammatory response with increased tissue injury and organ dysfunction.

SUMMARY

Critical illness-related corticosteroid insufficiency is common in critically ill patients, particularly those with sepsis. Supplemental corticosteroids may restore the balance between the pro-and anti-inflammatory mediators in patients with severe sepsis, septic shock and acute respiratory distress syndrome, and thereby improve the outcome of patients with these conditions.

Indications and practical use of replacement dose of corticosteroids in critical illness

PURPOSE OF REVIEW

Ongoing and severe systemic inflammation affecting critically ill patients may cause adrenal insufficiency and steroid resistance in target cells. As the appropriate diagnosis of this clinical entity remains a challenge, indication and practical use of corticosteroid replacement therapy in the critically ill is generally directed by clinical symptoms and features.

RECENT FINDINGS

In the last 2 years, a series of clinical trials have been undertaken to investigate corticosteroid replacement therapy in critically ill patients with severe systemic inflammation of various origin. Improvements of morbidity have been demonstrated in some studies. The data of recent studies should lead to a restriction of corticosteroid replacement therapy in critically ill patients. The purpose of this review is to investigate indications and the best current practical use of corticosteroid replacement therapy in critically ill patients in the absence of accurate laboratory assessment of adrenal insufficiency.

SUMMARY

Corticosteroid replacement therapy may improve morbidity and mortality in specific target groups of critically ill patients. The appropriate target groups remain to be refined. To demonstrate this, additional studies are required on endocrine disorder in critical illness and corticosteroid replacement therapy.

Relative adrenal insufficiency in patients with severe acute pancreatitis

OBJECTIVE

Inadequate cortisol levels and adrenal dysfunction may play a role in the pathophysiology of severe acute pancreatitis. This study aimed to analyse the incidence of relative adrenal insufficiency (RAI) in these patients, to identify factors associated with RAI and to describe how adrenal responsiveness affects outcome.

DESIGN

Prospective observational multicenter study.

PATIENTS

Twenty-five patients with severe acute pancreatitis.

INTERVENTIONS

A short Synacthen test (SST) was performed within 5 days after admission to the hospital. The incidence of RAI, defined as an increment after SST of less than 9 microg/dl was the primary endpoint of the study. Serum cortisol was measured at baseline and at 30 and 60 min after administration of 250 microg adrenocorticotropic hormone.

MEASUREMENTS AND RESULTS

Median baseline cortisol level was 26.6 microg/dl, and increased to 43.2 microg/dl and 48.8 microg/dl after 30 min and 60 min respectively. RAI was found in 16% of all patients and in 27% of patients with organ dysfunction. Patients with RAI were more severely ill and had higher SOFA scores from days 4 to 7 after admission. All patients with RAI developed pancreatic necrosis, and all of them needed surgical intervention. Twenty-eight-day mortality was significantly higher in patients with RAI (75% vs. 5%, p =0.007). Patients who died had a lower increment in cortisol levels after the SST than patients who survived.

CONCLUSION

RAI is frequent in patients with severe acute pancreatitis and organ dysfunction. It occurs in patients with more severe pancreatitis and is associated with increased mortality.

Upregulation of human angiotensinogen (AGT) gene transcription by interferon-gamma: involvement of the STAT1-binding motif in the AGT promoter

Mechanisms to maintain blood pressure in the face of infection are critical to survival. The angiotensinogen (AGT) gene locus is an important component of this response. Thus the AGT gene, expressed predominantly by liver cells, is known to be a positive acute phase reactant. We have previously demonstrated activation of the AGT promoter in hepatocytes through the IL6/STAT3 signaling mechanism. We have now investigated whether IFN-gamma, a cytokine also induced in response to diverse infections, can regulate AGT gene expression, and have elucidated the molecular mechanism involved. IFN gamma treatment up-regulated AGT mRNA level and promoter activity in Hep3B hepatocytes. Sequential deletion of the promoter from the 5' side suggested the major IFN gamma responsive DNA element to be between -303 and -103. This region contained a candidate STAT1-binding site between -271 and -279. EMSA and chromatin immuno-precipitation (ChIP) assays confirmed that IFN-gamma treatment induced the binding of STAT1 to this element. Reporter constructs containing this AGT promoter derived element in a multimerized context but not a mutant version were responsive to IFN gamma. Moreover mutating this STAT1 element in the context of the wild-type AGT holo promoter reduced responsiveness to IFN gamma. In contrast to the clear synergism between dexamethasone and IL 6 in the upregulation of the AGT promoter (through interaction between GR and STAT3), the combination of IFN gamma with IL 6 or with dexamethasone did not further increase AGT promoter activity suggesting that the IFN gamma/STAT1 pathway represents a separate signaling mechanism. These data highlight the redundancy in cytokine-mediated host response pathways aimed at the maintenance of blood pressure during infection.

Influence of hydrocortisone, prednisolone, and NO association on the evolution of acute pancreatitis

Leukocyte activation, inflammatory up-regulation, and microcirculatory disruption associated with ischemia-reperfusion injury are hallmarks in the pathogenesis of acute pancreatitis (AP). NO donors ensure microvascular integrity, while glucocorticoids act as anti-inflammatory and immune modulator drugs. AP was induced by the biliopancreatic duct outlet exclusion-closed duodenal loops (BPDOE-CDLs) model. Treatment with hydrocortisone (6 mg/kg) or prednisolone (0.5 mg/kg) alone or together with DETA-NO (0.5 mg/kg) was done (a)1 hr pre or (b)1 hr post, or (c) 1 hr pre and 4 hr post ,or (d) 4 hr post triggering AP. NOS inhibition by L-NAME (15 mg/kg) and glucocorticoid receptor blockage by mifepristone (3 mg/kg) was considered. AP severity was assessed by biochemical and histopathological analyses. Treatment with glucocorticoids together with DETA-NO 1 hr pre and 4 hr post BPDOE-CDLs reduced serum amylase, lipase, C-reactive protein, IL-6, IL-10, hsp72, and 8-isoprostane as well as pancreatic and lung myeloperoxidase. Acinar and fat necrosis, hemorrhage, and neutrophil infiltrate were also decreased. Hydrocortisone together with DETA-NO rendered the best results. We conclude that AP severity was significantly diminished by glucocorticoids associated with DETA-NO, with the optimal dose and time point of administration being crucial to provide adequate protection against AP.