Saturday, November 17, 2007

More clinical pearls from the hospital medicine CME conference

Continuing from my last post---

How should doctors decide whether to administer corticosteroids to patients with septic shock in the wake of the surprising findings of CORTICUS, which failed to show benefits from such therapy? This and related questions were discussed by Dr. Charles Abboud of the endocrinology section at Mayo Clinic. First it must be remembered that CORTICUS did not address “classic” adrenal failure which can occur in critical illness as a result of bilateral adrenal hemorrhage, bilateral adrenal infarction or, most commonly, suppression of the HPA axis as a result of prior corticosteroid therapy. Instead, CORTICUS applies to the concept of relative adrenal insufficiency, also known as “adrenal exhaustion” more recently termed “critical illness related corticosteroid insufficiency” (CIRCI). There is no dispute about the need to identify and treat classic adrenal insufficiency, either primary or secondary, in acutely ill patients. But in view of the recent CORTICUS results the treatment of CIRCI has become controversial.

CORTICUS was recently reviewed at the 72nd Annual International Scientific Assembly of the American College of Chest Physicians and at the Society of Critical Care Medicine 36th Critical Care Congress. The CORTICUS patients were less ill than those in other studies showing benefits of corticosteroid treatment. Also the study was halted before its enrollment target was met. From the Medscape report of the ACCP presentations:

Clinicians, nonetheless, must choose if and how to utilize corticosteroids. Hence, restricting their employment to persons who resemble those studied by Annane and colleagues might be the most prudent course as there are clinical trial findings to support this. Broad, routine administration of corticosteroids in severe sepsis and shock seems unwarranted at present.

Acknowledging the controversy raised by CORTICUS, Dr. Abboud believes that over 60% of patients with septic shock have CIRCI and recommends treating with corticosteroids if appropriate testing indicates its presence. His testing criteria seem to me more rigorous than other recommendations I’ve seen for evaluating CIRCI (any cortical value over 20 rules it out; subtract 5 from this cutoff value to account for decreased cortical binding if the serum albumin is below 2.5) and may select more severely ill patients, and hence those more likely to benefit. Dr. Abboud advises clinicians to closely follow the evidence in this evolving controversy.

Although guidelines now exist to help determine the duration of warfarin treatment following VTE there are controversies and gray areas. For such patients, measurement of D dimer levels 3-4 weeks following discontinuation of warfarin can help determine the risk of recurrent VTE. This enables a quantitative estimate which can be weighed against the estimated bleeding risk.

In a single center study of patients admitted with unexplained severe COPD exacerbation, with no initial suspicion of PE, PE was found in 25%.

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