Adrenocortical function: An indicator of severity of disease and survival in chronic critically ill patients

Abstract

Plasma cortisol levels and modified Apache II (Apache IIm-stay) severity of disease scores were determined at weekly intervals in 159 patients who were treated for at least 7 days at the Critical Care Unit of our hospital. The mean (+/- SD) plasma cortisol level (0.60 +/- 0.28 mumol/l) was clearly elevated in these patients. The highest plasma cortisol levels were measured in patients treated with vasoactive drugs (0.76 +/- 0.39 mumol/l). Non-survivors (n = 36) had a significantly higher mean plasma cortisol level and Apache IIm-stay score than survivors (respectively 0.78 +/- 0.40 vs. 0.54 +/- 0.21 mumol/l; p less than 0.0003 and 12.6 +/- 4.8 vs. 7.3 +/- 4.1; p less than 0.0001). A significant correlation was found between the individual weekly plasma cortisol levels and the Apache IIm-stay scores (r = 0.41; p less than 0.0001), especially in the subgroup of patients, who never received glucocorticoids during their stay at the ICU (r = 0.51; p less than 0.0001). During the 14-month study period only two patients showed a clinical picture of adrenocortical insufficiency and a blunted response of cortisol to 0.25 mg synthetic ACTH(1-24). In conclusion, our data suggest that a high plasma cortisol level, like a high Apache IIm-stay score, indicates severity of disease and poor survival in critically ill patients. De novo adrenocortical insufficiency is rare and therefore routine screening of adrenocortical function is superfluous.

Adrenocortical function during septic shock

“…Single plasma cortisol determinations have been correlated with severity of illness and mortality in a large population of ICU patients [3,8,24]. Patients with high cortisol levels are likely to have a poor prognosis.…”

“…However, previous studies of adrenal function using the short synthetic ACTH (corticotrophine) stimulation test in intensive care unit (ICU) patients report various incidences of adrenocortical insufficiency ranging from 0-41 o7o [2,4]. Adrenocortical function as a prognostic factor in ICU patients has also been suggested in recent reports [3,8,10], but in a well-defined population of patients with septic shock plasma cortisol concentrations were not predictive of the clinical outcome [4]. These conflicting results raise practical questions: is routine determination of serum cortisol concentration useful?…”

“…Patients with bacterial infection [5,6], septic shock [4], or during other acute medical [3,7,8] or surgical [9] illness generally have increased plasma cortisol concentrations 9 Although adrenocortical insufficiency seems to be uncommon in critically ill patients [3,8], diagnosis of hypocortisolism is vital to survival from septic insults and suggests urgent intravenous hydrocortisone therapy. However, previous studies of adrenal function using the short synthetic ACTH (corticotrophine) stimulation test in intensive care unit (ICU) patients report various incidences of adrenocortical insufficiency ranging from 0-41 o7o [2,4].…”

On the Neuroendocrinopathy of Critical Illness. Perspectives for Feeding and Novel Treatments

“…55,65 An appropriate activation of the hypothalamic-pituitary-adrenal axis and cortisol response to acute critical illness is vital. [72][73][74][75][76][77] The vital stress-induced hypercortisolism in critically ill patients improves the hemodynamic status through fluid retention and vasopressorsensitization, provides energy via shifting carbohydrate, fat and protein metabolism, and protects against excessive inflammation by suppressing inflammation. 1,67 The pituitary-adrenocortical axis in the prolonged phase of critical illness…”

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

“…2,3,9,[11][12][13][14][15][16] However, most studies of intensive care unit (ICU) populations (excluding patients receiving chronic steroids) have shown very low rates (<2%) of patients with true adrenocortical insufficiency (AI). 2,3,9,12,14 In countries such as Taiwan, cultural and medical differences may influence the incidence of secondary AI in the patient population. Many patients use herbal remedies in addition to western medical therapies, believing the combination improves their chance of recovery.…”