Diagnosis of Adrenal Insufficiency in Severe Sepsis and Septic Shock

Annane, Djillali; Maxime, Virginie; Ibrahim, F.; Alvarez, Jean‐Claude; Abé, Emuri; Boudou, Philippe

doi:10.1164/rccm.200509-1369oc

Cited by 299 publications

(279 citation statements)

References 30 publications

Supporting

Mentioning

250

Contrasting

Unclassified

Order By: Relevance

“…This issue was refuted by others, however [5,15,21]. Differences in case mix may partly underlie the discrepancies between studies, because of healthy volunteers or non-septic patients predominating in some studies [4,11,14,17] and of septic patients in others [5,15,21]. Moreover, CIRCI may be more frequent in sepsis than in non-sepsis patients, and sometimes only calculated free cortisol was evaluated, thereby assuming normal albumin levels, while both CBG and albumin may be lowered [1-3, 5, 6, 8, 18, 22, 23].…”

Section: Introductionmentioning

confidence: 95%

“…Indeed, low binding proteins may overestimate relative adrenal insufficiency assessed from (increases in) total cortisol. This issue was refuted by others, however [5,15,21]. Differences in case mix may partly underlie the discrepancies between studies, because of healthy volunteers or non-septic patients predominating in some studies [4,11,14,17] and of septic patients in others [5,15,21].…”

Section: Introductionmentioning

confidence: 98%

“…Relatively insufficient adrenal secretion of cortisol for the severity of illness, in the course of critical illness-related corticosteroid insufficiency (CIRCI), commonly occurs in the critically ill. This may warrant treatment by corticosteroids to survive septic shock, although this is hotly debated [2][3][4][5][6][7]. Adrenal function is mostly assessed by total cortisol measurements prior to and after injection of adrenocorticotropic hormone (ACTH).…”

Section: Introductionmentioning

confidence: 99%

“…Adrenal function is mostly assessed by total cortisol measurements prior to and after injection of adrenocorticotropic hormone (ACTH). Insufficiency is usually defined at cutoffs of peak levels, increases of circulating cortisol upon ACTH (\250 nmol/l) or combinations of these [1][2][3]5].…”

Section: Introductionmentioning

confidence: 99%

“…Foregoing studies can be criticized because of changes in binding proteins such as cortisol-binding globulin (CBG) and albumin, confounding estimation of biologically active free cortisol from total cortisol measurements and thereby assessment of adrenal function [1,4,5,[7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Indeed, low binding proteins may overestimate relative adrenal insufficiency assessed from (increases in) total cortisol.…”

Section: Introductionmentioning

confidence: 99%

See 4 more Smart Citations

Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness

et al. 2011

View full text Add to dashboard Cite

Purpose: To study the value of free versus total cortisol levels in assessing relative adrenal insufficiency during critical illnessrelated corticosteroid insufficiency. Methods: A prospective study in a mixed intensive care unit from 2004 to 2007. We consecutively included 49 septic and 63 non-septic patients with treatment-insensitive hypotension in whom an adrenocorticotropic hormone (ACTH) test (250 lg) was performed. Serum total and free cortisol (equilibrium dialysis), corticosteroid-binding globulin (CBG) and albumin were assessed. Results: Although a low CBG resulted in a high free cortisol level relative to total cortisol, free and total cortisol and their increases were well correlated (r = 0.77-0.79, P \ 0.001). In sepsis, hypoalbuminemia did not affect total and free cortisol, and increases in total cortisol upon ACTH predicted increases in free cortisol regardless of low binding proteins. In non-sepsis, total cortisol was lower with than without hypoalbuminemia; free cortisol did not differ, since hypoalbuminemia concurred with a low CBG. Increases in total cortisol depended less on binding proteins than on raw levels. The areas under the receiver operating characteristic curve for predicting increases in free from total cortisol were 0.93-0.97 in sepsis and 0.79-0.85 in non-sepsis (P = 0.044 or lower for sepsis vs. non-sepsis). Conclusions: Although the biologically active free cortisol fraction depends on binding proteins, total cortisol correlates to free cortisol in treatment-insensitive hypotension during critical illness. In sepsis, albumin is not an important binding molecule. Subnormal increments in total cortisol upon ACTH suffice in assessing relative adrenal insufficiency, particularly in sepsis.

show abstract

Section: Introductionmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness

et al. 2011

View full text Add to dashboard Cite

show abstract

Using Corticosteroids in Intensive Care

Marik¹

2006

Arch Surg

View full text Add to dashboard Cite

Low-Dose Corticosteroids for Critically Ill Adults With Severe Pulmonary Infections

Pirracchio,

Venkatesh,

Legrand

2024

JAMA

View full text Add to dashboard Cite

ImportanceSevere pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%.ObservationsCorticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections.Conclusions and RelevanceTreatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.

show abstract

Diagnosis of Adrenal Insufficiency in Severe Sepsis and Septic Shock

Abstract: In sepsis, adrenal insufficiency is likely when baseline cortisol levels are less than 10 microg/dl or delta cortisol is less than 9 microg/dl, and unlikely when cosyntropin-stimulated cortisol level is 44 microg/dl or greater or Delta cortisol is 16.8 microg/dl or greater.

Cited by 299 publications

References 30 publications

Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness

Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness

Using Corticosteroids in Intensive Care

Low-Dose Corticosteroids for Critically Ill Adults With Severe Pulmonary Infections

Contact Info

Product

Resources

About