Insuficiência adrenal relativa como preditora de gravidade de doença e mortalidade do choque séptico

Abstract

ObjectiveTo evaluate if cortisol responses to 250 µg of intravenously administered adrenocorticotropic hormone are related to disease severity and, hence, mortality. MethodsThis is a retrospective study in a medical-surgical intensive care unit of a university hospital. We studied 69 consecutive patients with septic shock over a 1-yr period; these patients underwent a short 250-µg adrenocorticotropic hormone test because they exhibited >6 hours of progressive hemodynamic instability requiring repeated fluid challenges and vasopressor treatment to maintain blood pressure. The test was performed by intravenously injecting 250 µg of synthetic adrenocorticotropic hormone and measuring cortisol immediately before injection, 30 minutes post-injection and 60 minutes post-injection. ResultsThe mean APACHE II score was 22±7. The intensive care unit mortality rate at day 28 was 55%. Median baseline cortisol levels (19 [11-27] µg/dL versus 24 [18-34] µg/dL, p=0.047) and median baseline cortisol/albumin ratios (7.6 [4.6-12.3] versus 13.9 [8.8-18.5]; p=0.01) were lower in survivors than in non-survivors. Responders and non-responders had similar baseline clinical data and outcomes. The variables that were significantly correlated with outcome based on the area under the ROC curves (AUC) were APACHE II (AUC=0.67 [0.535 to 0.781]), baseline cortisol (µg/dl) (AUC=0.662 [0.536 to 0.773], peak cortisol (µg/dl) (AUC=0.642 [0.515 to 0.755]) and baseline cortisol/albumin (AUC=0.75 [0.621 to 0.849]). ConclusionsIncreased basal cortisol is associated with mortality and disease severity. Cortisol responses upon adrenocorticotropic hormone stimulation were not related to outcome. The cortisol/albumin ratio does not predict unfavorable outcomes better than total cortisol levels or help to improve the accuracy of the adrenocorticotropic hormone test.

Septic shock and the use of norepinephrine in an intermediate care unit: Mortality and adverse events

“…The median APACHE-II score was 26, and the median age was 81 years in this retrospective study. In other studies, patients with septic shock [ 17 – 19 ] with a respective mean APACHE-II score of 22, 20 and 24 had reported a median age of 57, 54 and 32 years, respectively. The higher APACHE-II score in this study could partly be explained by the advanced age of the included patients.…”

The effect of physiologic dose of intravenous hydrocortisone in patients with refractory septic shock: a randomized control trial

“…Mortality also had a significant difference in intervention shock which were given low dose of hydrocortisone, the mortality rate differed significantly (17). In a retrospective study on refractory septic shock with 28-day mortality of 55%, they concluded that higher basal cortisol level was related with higher mortality and response to cosyntropin test did not relate to outcome (18). In the last version of international guidelines for management of severe sepsis and septic shock, there is no recommendation for hydrocortisone administration in septic shock.…”