Adrenal Insufficiency in Critically Ill Emergency Department Patients: A Taiwan Preliminary Study

Abstract

Abstract. Objective: Unrecognized adrenal insufficiency can have serious consequences in critically ill emergency department (ED) patients. This prospective pilot study of adrenal function in patients with severe illness was undertaken to determine the prevalence of adrenal dysfunction and any relation to prior herbal drug use. Methods: In a high-volume urban tertiary care ED, adult patients with sepsis or acute myocardial infarction (AMI) were eligible for the study. Over a two-month period, a convenience sample was enrolled by the authors on arrival to the ED. Inclusion criteria were systemic inflammatory response syndrome (SIRS) criteria plus evidence of at least one organ dysfunction or cardiac marker plus electrocardiogram-proven AMI. Exclusion criteria included known corticosteroid use. Serum cortisol was measured on arrival and for those patients with a level of <15 g/dL (<414 nmol/L), an adrenocorticotropic hormone (ACTH) stimulation test was performed. Results: Of the 30 enrolled patients, 23 (77%) were suffering from severe sepsis and the other seven (23%) had an AMI. Thirteen of the 30 patients (43%; 95% CI = 25% to 65%) had serum cortisol levels of <15 g/dL, consistent with adrenal insufficiency, nine with severe sepsis and four with an AMI. Eight (62%; 95% CI = 32% to 86%) of the 13 patients with low cortisol levels reported using herbal medications, while only two (12%; 95% CI = 1% to 36%) of the 17 with normal cortisol levels reported taking herb drugs (p = 0.01). Only two (15%; 95% CI = 2% to 45%) of the patients with low cortisol levels failed their corticotropin stimulation test, suggestive of true adrenocortical insufficiency. Both reported using herbal preparations. Conclusions: These results indicate that adrenal dysfunction is common among a group of critically ill patients seen in this Taiwanese ED. Moreover, the use of herbal drugs was high in the patients with low serum cortisols. Further studies are required to both confirm these findings and clarify whether a number of herbal medications contain corticosteroids.

Relative Adrenal Insufficiency in Dogs with Sepsis

“…Relative adrenal insufficiency (RAI) has been reported in up to 77% of humans with septic and nonseptic critical illness. [5][6][7][8][9][10][11][12][13][14] It is generally characterized by basal serum cortisol concentration within or above the reference range and a blunted cortisol response after ACTH administration, suggesting that the adrenal cortex can make and release cortisol, but the quantity of cortisol produced is inadequate for the degree of physiologic stress.…”

Impact of Fluconazole Prophylaxis on Cortisol Levels in Critically Ill Surgical Patients

“…Estimates of the prevalence of adrenal dysfunction among critically ill patients vary widely, from 0.66 to over 40%, depending on the definition of adrenal dysfunction and the specific patient population studied (3,6,9,25,35,36,40). Drugs administered to such patients may contribute to adrenal dysfunction by increasing the rate at which cortisol is metabolized (20) or, as in the case of etomidate (8,46) or ketoconazole (26,30,33,34), by inhibiting enzymes in the steroid biosynthetic pathway.…”

Comment on: Reduced plasma levels of NGF and BDNF in patients with acute coronary syndromes

“…Indeed, ACS is a highly dynamic phenomenon associated with neuroendocrine and proinflammatory activation ( [3], also see Mackin and Gallagher's refs. [3,4]), and, note, including adrenal insufficiency [4]. We may argue that reduced NGF/BDNF plasma levels in ACS are not due to stress-induced elevated cortisol presence in ACS.…”