Adrenal Insufficiency in High-Risk Surgical ICU Patients

Rivers, Emanuel P.; Gaspari, Mario; Mlynarek, Mark; Horst, Harriette; Fath, John J.; Wortsman, Jacobo; Saad, George Abi

doi:10.1378/chest.119.3.889

Cited by 140 publications

(127 citation statements)

References 47 publications

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“…The relationship between adrenal insufficiency and sepsis in humans, however, is complex. Critically ill patients are at increased risk for developing sepsis, the overall incidence of adrenal insufficiency in critically ill patients approximates 30%, and adrenal insufficiency is particularly common in septic patients (7,20,27). It has also been shown, however, that sepsis can lead to adrenal insufficiency (17,30,38).…”

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confidence: 99%

Endogenous and Exogenous Glucocorticoids in Experimental Enterococcal Infection

Papasian

Qureshi

Morrison

2006

Clin Vaccine Immunol

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The potentially protective role of the host adrenal-glucocorticoid response to enterococcal infection was evaluated in an experimental model in which mice were infected intraperitoneally with two distinct Enterococcus faecalis strains (K9 and CP-1). We demonstrated that corticosterone levels in serum and peritoneal-lavage fluid were elevated within 1 hour of infection with either E. faecalis strain. We also demonstrated that adrenalectomized mice generated a more robust localized peritoneal tumor necrosis factor alpha (TNF-␣) response to both E. faecalis strains than did sham-adrenalectomized mice but that neither E. faecalis strain induced a systemic TNF-␣ response. Further, peritoneal TNF-␣ production in adrenalectomized mice infected with either E. faecalis K9 or CP-1 was suppressed by prior treatment with an exogenous glucocorticoid (dexamethasone). The potential clinical significance of these results was suggested by our findings that adrenalectomy markedly increased susceptibility (a >100-fold decrease in the 50% lethal dose) to lethal infections with E. faecalis CP-1 and that prior dexamethasone treatment partially compensated for adrenalectomy. In marked contrast to these findings, however, adrenalectomy did not substantially increase susceptibility to lethal E. faecalis K9 infection. Further, preinfection with E. faecalis CP-1 1 hour before infection with E. faecalis K9 did not protect mice from lethal E. faecalis K9 infections. Collectively, these studies indicate that the host can generate a glucocorticoid response to E. faecalis infection that suppresses TNF-␣ production. Further, this glucocorticoid response can protect the host from potentially lethal E. faecalis infections, but different strains show heterogeneity with respect to the extent of protection afforded by the adrenal-glucocorticoid response.

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confidence: 99%

Endogenous and Exogenous Glucocorticoids in Experimental Enterococcal Infection

Papasian

Qureshi

Morrison

2006

Clin Vaccine Immunol

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“…the severity of the sepsis in these patients. In contrast, the research papers cited in the subtitle of this review, the hypothalamus-pituitary-adrenal axis and cortisol secretion, demonstrate that among patients with critical diseases the average base cortisol level was found to be above 25 µg/dl and in work by Rivers et al, 24 and also by Marik and Zaloga,26 this point represented patients on vasopressors who responded or not to corticosteroid therapy, probably indicating that this group of patients had an adrenal response which was inadequate for the level of stress. We therefore believe that base cortisol levels above 25 µg/dl are the safest indication of patients in septic shock who have an adequate adrenal response.…”

Section: Final Commentsmentioning

confidence: 63%

“…Bone et al, 18 in work published in 2002, in which they studied 65 children with meningococcal disease, found an average cortisol level at admission of 41.5 µg/dl (1122 nmol/l). Rivers et al 24 evaluated adrenal function in 104 patients submitted for surgery who required vasopressors and found an average baseline cortisol of 29.9 µg/dl. In this study, a group of patients treated with corticosteroid presented a good response with withdrawal of the vasopressors in 24 hours.…”

Section: The Hypothalamus Pituitary Adrenal Axis and Cortisol Secretionmentioning

confidence: 99%

Insuficiência adrenal na criança com choque séptico

Casartelli¹,

García²,

Piva³

et al. 2003

J. Pediatr. (Rio J.)

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Objective: To review the criteria for diagnosing and treating adrenal insufficiency in patients with septic shock. Sources of data:Articles published in Brazilian and foreign journals selected through these publications' websites and Medline, as well as references cited in key articles Summary of the findings:The literature reports a range betwen 17 and 54 % for the finding of adrenal insufficiency in patients with septic shock. There is no consensus for diagnosing adrenal insufficiency in patients suffering from critical diseases, particularly in patients with septic shock. The presence of volumerefractory and catecholamine-resistant septic shock suggests this condition, while basal cortisol under 25 µg/dl is a diagnostic criterion indicating adrenal insufficiency. The adrenal stimulation test is a useful resource for identifying patients with relative adrenal insufficiency. Our testing option for adrenal stimulation in children is the use of corticotropin in low doses (0.5 µg/1,73 m²). An increase of less than 9 µg/dl in the value of postcorticotropin-stimulated cortisol suggests the presence of occult (relative) adrenal insufficiency. In patients with septic shock presenting adrenal insufficiency, either suspected or confirmed, the administration of hydrocortisone in shock or stress doses can be vital for a favorable clinical outcome. Conclusions:The existing data, although controversial, already provides a basis to determine when to begin hormone replacement therapy, the serum level of cortisol accepted as adequate, and the choice of corticotropin doses for performing the adrenal stimulation test and diagnosing occult or relative adrenal insufficiency in patients with septic shock. J Pediatr (Rio J) 2003;79(Suppl 2):S169-S76: Sepsis, septic shock, adrenal cortex, adrenal gland hypofunction, glucocorticoids, adrenal cortex function tests.

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“…Absolute adrenal insufficiency is rare among critically ill patients, with an incidence estimated to be ≤3 percent 25 . However, observations argue that suboptimal cortisol production may be more common and associated with worse outcomes.…”

Section: Prevalencementioning

confidence: 99%

“…24, 25 Baseline and/or post-ACTH serum cortisol <23.7 mcg/dL (670 nmol/L) predicts AI and responsiveness to exogenous steroids in septic shock (that is patient will Respond with steroid treatment). Responsiveness is defined by the ability to maintain a Mean Arterial Blood Pressure >65 mmHg without norepinephrine infusion within 24 hours after starting hydrocortisone 26 .…”

Section: High Dose (250 Mcg) Testmentioning

confidence: 99%

Adrenal Insufficiency In Critically Ill Patients

Ashrafuzzaman

2015

Bangladesh Crit Care J

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Adrenal insufficiency means hypo function of the adrenal cortex, usually resulting in low glucocorticoid level and it may be associated with low mineralocorticoid, rarely low adrenal androgen level. It can be categorized into two types: primary and secondary. Primary adrenal insufficiency or Addison's disease is associated with low cortisol and high ACTH level. Secondary/tertiary adrenal insufficiency is due to pituitary or hypothalamic disorders and is associated with both low cortisol and ACTH level. Among critically ill patients (CIP) adrenal insufficiency is not uncommon. The reported incidence of adrenal insufficiency varies greatly depending on the population of critically ill patients studied, the type of test, cut off levels used, and the severity of illness. Several studies have shown increased mortality in patients with very low or very high baseline cortisol levels. Manifestations of adrenal insufficiency in the critically ill patient are numerous and nonspecific, so clinicians are urged to have a high index of suspicion while taking history and doing physical examination and be alert to important diagnostic clues, such as hyponatremia, hyperkalemia, and hypotension, that are refractory to fluids and vasopressor without any clear causation. In current literature there is no consensus level of cortisol (basal/random/stimulated) in critically ill subjects. But it is shown that both high and low cortisol level is associated with increased mortality. In one study Basal Serum Cortisol <414 nmol/L and > 696 nmol/L is shown as indicative of higher risk among critically ill patients. Even with Septicemia or ARDS all subjects dont suffer from adrenal insufficiency often termed relative adrenal insufficiency or critical illness associated adrenal insufficiency. It has been observed that short term low dose IV hydrocortisone may be beneficial in selective group of patients in intensive care unit (ICU) with critical illness. Diagnosis of adrenal insufficiency associated with critical illness is still challenging for physicians working in ICU. Treatment should be started without delay in emergency situation with Injection Hydrocortisone intravenously or even intramuscularly. Since the condition appears to be common in patients with septic shock, clinicians should have a high index of suspicion for its occurrence in critically ill patients with persistent hypotension despite adequate fluid resuscitation and/or poor hemodynamic response to vasopressor. Adrenal insufficiency associated with other illnesses in ICU are attributed to previous primary or secondary adrenal insufficiency. Treatment with physiologic doses of corticosteroids should be started as soon as possible since short-term treatment carries very few risks and has been shown to decrease both morbidity and mortality. Only suspected cases should be evaluated and could be treated with 100-200 mg Hydrocortisone in divided doses for 5-7 days. Glucocorticoid cannot be recommended as a routine adjuvant therapy in all cases of septic shock or ARDS. But glucocorticoid earned its position among other rescue strategies in subgroups of ICU patients with the highest mortality risk. Steroid use is an art and needs to be used by experienced physician. Otherwise it may do more harm than benefit.Bangladesh Crit Care J March 2015; 3 (1): 27-30

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Adrenal Insufficiency in High-Risk Surgical ICU Patients

Cited by 140 publications

References 47 publications

Endogenous and Exogenous Glucocorticoids in Experimental Enterococcal Infection

Endogenous and Exogenous Glucocorticoids in Experimental Enterococcal Infection

Insuficiência adrenal na criança com choque séptico

Adrenal Insufficiency In Critically Ill Patients

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