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Chapter 26. Effects of Critical Illness in the Surgical Intensive Care Unit

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A 57-year-old man is admitted from an outside hospital to your intensive care unit (ICU) in shock. Past medical history is significant for Crohn disease and a recent flare in the past month requiring prednisone. He underwent a laparoscopic cholecystectomy 1 week prior to transfer and has been having increasing abdominal pain for the past 3 days. Despite fluid resuscitation, he still requires norepinephrine and vasopressin infusions to maintain mean arterial pressure (MAP) >65 mm Hg. There is suspicion of relative adrenal insufficiency. Which of the following interventions is the best next step?

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A. Measure baseline total cortisone level

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B. Initiate hydrocortisone treatment

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C. Adrenocorticotropic hormone (ACTH) stimulation test

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D. Assay of cellular activity of cortisol

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B. Suboptimal cortisol production during septic shock has been termed functional or relative adrenal insufficiency. The adrenal suppression in critically ill patients is often reversible, and there is no consensus about indications for its treatment or diagnostic criteria. Also, there is no consensus over what cortisol level is normal in septic shock, what constitutes an adequate response to ACTH, and what dose of synthetic ACTH should be used for stimulation testing. Adrenal suppression should be suspected when critically ill patients do not respond to volume resuscitation, especially in patients who have recently been on steroid treatment. There is a possibility that glucocorticoid resistance exists at receptor level and assay of cellular activity of cortisol can be used to assess it, but it is still experimental and not clinically relevant.

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As per the available evidence at present, there is no advantage of steroids in patients with severe sepsis not in septic shock. In patients with refractory septic shock, it is reasonable to administer hydrocortisone therapy. ACTH stimulation test is not recommended prior to initiating steroid therapy in these patients because it cannot reliably differentiate between responders and nonresponders to therapy.

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How do the Centers for Medicare and Medicaid Services in the United States define prolonged mechanical ventilation?

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A. 7 days of mechanical ventilation for at least 12 hours per day

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B. 14 days of mechanical ventilation for at least 6 hours per day

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C. 14 days of mechanical ventilation for at least 12 hours per day

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D. 21 days of mechanical ventilation for at least 6 hours per day

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D. Prolonged mechanical ventilation (PMV) is defined by the Centers for Medicare and Medicaid Services in the United States as greater than 21 days of ...

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