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CIRCI — Adrenal Insufficiency Algorithm

ICU patients with suspected CIRCI · March 2026 edition

Refractory septic shock: do NOT delay treatment for cosyntropin testTaper: do NOT stop abruptly

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) · ICU Protocol

Phase 1

Risk assessment

Refractory septic shock despite fluids + vasopressors
Recent/chronic steroid use
Etomidate exposure

Septic shock refractory to vasopressors?

YESEmpiric hydrocortisone ↓NOConsider stim test ↓

YES

Empiric hydrocortisone

Start empiric hydrocortisone

Do NOT delay treatment for cosyntropin test

Consider empiric treatment while awaiting results

Phase 2

Treatment protocol

Hydrocortisone

50 mg IV q6h (200 mg/day)

or continuous infusion 200 mg/24h

± Fludrocortisone 50 mcg PO/NG daily (conditional)
Monitor glucose q4h (steroid hyperglycemia)

Then: clinical response within 24–48h? ↓

NO

Consider stim test

Consider cosyntropin stimulation test

Draw baseline cortisol
Give Cosyntropin 250 mcg IV
Draw cortisol at 30 and 60 min

Delta cortisol < 9 mcg/dL: = adrenal insufficiency
Random cortisol < 10 mcg/dL: = suggestive

Etomidate causes adrenal suppression for 24–48h.

If patient received etomidate, consider empiric stress-dose steroids regardless of stim test.

Phase 2: Treatment protocol ↑Then: clinical response within 24–48h? ↓

Clinical response within 24–48h?Vasopressor wean, hemodynamic improvement

YESPhase 3: Taper ↓NOReassess diagnosis ↓

YES

Phase 3: Taper

Continue hydrocortisone until vasopressors weaned

Then taper over 5–7 days

50 mg q6h
50 mg q8h
50 mg q12h
stop

Do NOT stop abruptly

NO

Reassess diagnosis

Consider alternative causes of shock
Rule out ongoing septic source
Endocrine consult if unclear

Contraindications: active fungal infection