Adrenal Dysfunction in Hemodynamically Unstable Patients in the Emergency Department

Abstract

Abstract. Objective: Adrenal failure, a treatable condition, can have catastrophic consequences if unrecognized in critically ill ED patients. The authors' objective was to prospectively study adrenal function in a case series of hemodynamically unstable (highrisk) patients from a large, urban ED over a 12-month period. Methods: In a prospective manner, critically ill adult patients presenting to the ED were enrolled when presenting with a mean arterial blood pressure Յ60 mm Hg requiring vasopressor therapy for more than one hour after receiving fluid resuscitation (central venous pressure of 12-15 mm Hg or a minimum of 40 mL/kg of crystalloid). Patients were excluded if presenting with hemorrhage, trauma, or AIDS, or if steroids were used within the previous six months. An adrenocorticotropic hormone (ACTH) stimulation test was performed and serum cortisol was measured. Treatment for adrenal insufficiency was not instituted. Results: A total of 57 consecutive patients were studied. Of these, eight (14%) had baseline serum cortisol concentrations of <20 g/dL (<552 nmol/L), which was considered adrenal insufficiency (AI). Three additional patients (5%) had subnormal 60-minute post-ACTH-stimulation cortisol responses (<30 g/dL) and a delta cortisol Յ9 g/dL, which is the difference between the baseline and 60-minute levels. This is functional hypoadrenalism (FH). There were no laboratory abnormalities that distinguished patients with AI or FH from those with preserved adrenal function (PAF). Rates of survival to discharge did not differ between the AI group (7 of 8) and PAF patients (21 of 46; p = 0.052). Conclusions: Adrenal dysfunction is common in high-risk ED patients. Overall, it has a frequency of 19% among a homogeneous population of hemodynamically unstable vasopressor-dependent patients. The effect of physiologic glucocorticoid replacement in this setting remains to be determined. Key words: adrenal insufficiency; adrenal dysfunction; hypotension; shock; emergency; functional hypoadrenalism; adrenal crisis; hypoadrenalism. ACADEMIC EMERGENCY MEDICINE 1999; 6:626-630 C ORTISOL is a major stress response hormone that has metabolic, catabolic, anti-inflammatory, and vasoactive properties on cardiac muscle and the peripheral vasculature. Cortisol mediates maintenance of peripheral vasomotor tone by facilitating catecholamine-induced vasoconstriction and it has a permissive effect on synthesis of catecholamines and vasoactive peptides.

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“…First, the development of vasodilatory shock: persistent hypotension (mean arterial pressure ≤ 60 mmHg) after adequate volume resuscitation to a central venous pressure between 12 and 15 mmHg [21] and requiring initiation of vasopressor therapy for greater than 24 hours. The second criterion was the presence of two or more of the following criteria for systemic inflammatory response syndrome: temperature >38.5°C or <35.6°C, white cell count >11,000 cells/mm 3 or <4,000 cells/mm 3 , immature neutrophils (bands) >10%, respiratory rate >20/minute, PaCO 2 <35 mmHg or requirement for mechanical ventilation, and heart rate >90/minute [22].…”

Food and Drug Administration Drug Approval Summary: Sunitinib Malate for the Treatment of Gastrointestinal Stromal Tumor and Advanced Renal Cell Carcinoma

“…Although no overt clinically important adrenal suppression was observed in patients taking sunitinib, patients receiving sunitinib while undergoing physiologic stressors such as infection, trauma, or surgery may be unable to mount an appropriate adrenal response due to subclinical adrenal toxicity. Such subclinical toxicity may be difficult to detect without unmasking by physiologic stress [8]. Physicians prescribing sunitinib are advised to monitor for adrenal insufficiency in patients who undergo stressors such as surgery, trauma, or severe infection.…”

Risk in Emergency Research Using a Waiver of/Exception from Consent: Implications of a Structured Approach for Institutional Review Board Review

“…Nontherapeutic procedures classified as more than minimal risk included a diagnostic peritoneal lavage that did not change patient management and possibly delayed surgery, 20 as well as an adrenocorticotropic hormone test (ACTH) stimulation test administered to measure the incidence of adrenal suppression in trauma patients. 38 A number of procedures were classified as probably minimal risk, but prompted disagreement between reviewers. These included: ultrasound examinations that had no bearing on clinical care, 21,59,69,71 blood and CSF sampling from indwelling catheters, 62,80 nontherapeutic arterial blood samples, 67 in trauma patients undergoing CT scanning of other body parts, 78 and the testing of blood samples (with identifying markers removed) taken from out-ofhospital cardiac arrest victims for HIV seropositivity 79 (Figure 2).…”