Hypocortisolaemia and adrenocortical responsiveness at onset of septic shock

Moran, J. L.; Chapman, M. John; O'Fathartaigh, M. S.; Peisach, A R; Pannall, P R; Leppard, P.

doi:10.1007/bf01711901

Cited by 151 publications

(92 citation statements)

References 32 publications

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“…11,12,29,30 Our study shows a prevalence of relative adrenal insufficiency reaching 76% in a homogenous group of patients with cirrhosis presenting with septic shock. Several potential mechanisms have been postulated, including adrenal exhaustion, 31 inhibition of cortisol synthesis by tumour necrosis factor-α 32 and, less likely, adrenal hemorrhage. 29 Despite this high prevalence of relative adrenal insufficiency, our study showed no survival benefit with hydrocortisone therapy, although hemodynamic parameters improved significantly.…”

Section: Discussionmentioning

confidence: 99%

Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial

Arabi¹,

Aljumah²,

Dabbagh³

et al. 2010

Canadian Medical Association Journal

183

200

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Section: Discussionmentioning

confidence: 99%

Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial

Arabi¹,

Aljumah²,

Dabbagh³

et al. 2010

Canadian Medical Association Journal

183

200

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“…In patients with septic shock, a decreased response to the SST, namely, an absolute increment of the serum cortisol level less than 9 g/dL, is associated with an impaired vascular reactivity to vasopressors 5 and a high mortality. [5][6][7][8][9] Patients with cirrhosis share many similar hemodynamic features with patients with septic shock and adrenal insufficiency, namely, increased cardiac output, decreased peripheral vascular resistance, decreased mean arterial pressure, and hypo-responsiveness to vasopressors. 1,[10][11][12][13] Consistent with observations in septic patients, hemodynamic impairment is closely related to mortality and morbidity in patients with cirrhosis.…”

mentioning

confidence: 99%

Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock

et al. 2006

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Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instabity and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 ؎ 8.0 vs. 8.5 ؎ 5.9 g/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End-Stage Liver Disease, and Child-Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 ؎ 14 vs. 74.5 ؎ 13 mm Hg, P < .001 ), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality. (HEPATOLOGY 2006;43:673-681.) C ritical illness is accompanied by the activation of the hypothalamic-pituitary-adrenal (HPA) axis, which is highlighted by increased serum corticotropin and cortisol levels. [1][2][3] The activation of the HPA axis is a crucial component of the host's adaptation to severe stress. Cortisol is essential for the normal function of the immune system, maintenance of vascular tone, and various cellular functions. In patients with severe sepsis, the integrity of the HPA axis can be impaired by a variety of mechanisms. 1,4 Recently, the concept of relative adrenal insufficiency has been used to describe a subnormal adrenal response to adrenocorticotropin in severe illness, in which the cortisol levels, even though high in terms of absolute value, are inadequate to control the inflammatory situation. 1 The short corticotropin stimulation test (SST) is most commonly used to evaluate the appropriateness of the adrenal response in this setting. In patients with septic shock, a decreased response to the SST, namely, an absolute increment of the serum cortisol level less than 9 g/dL, is associated with an impaired vascular reactivity to vasopressors 5 and a high mortalit...

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“…Nevertheless, several studies have reported a high mortality associated with high cortisol levels thought to be a function of the underlying severe illness. 5,6,10,11,20,24 In this study, mortality rate was also extremely high among the patients with PAF. In a recent study of cortisol kinetics during and after cardiopulmonary arrest in the ED, it was noted that failure to attain a cortisol level of at least 30 g/dL was associated with 100% mortality at 24 hours.…”

Section: Discussionmentioning

confidence: 54%

“…Rothwell et al, 25 who evaluated a group of 32 patients in septic shock and adequate 24 also noted a positive correlation between decreased response to the ACTH stimulation and increased mortality; moreover, patients had a low probability of responsiveness to ACTH within the 24 hours preceding their deaths. Nevertheless, several studies have reported a high mortality associated with high cortisol levels thought to be a function of the underlying severe illness.…”

Section: Discussionmentioning

confidence: 96%

“…25 In fact, it has been suggested that relative AI may be a contributing factor in poor outcomes in the setting of severe illness. 5,12,15,24,25 The clinical presentation of the ''high-risk'' AI is one who has been adequately fluid resuscitated with persistent hypotension often necessitating vasopressors for hemodynamic support. 27 Besides hypotension and decreased cardiac output, some patients with AI may present with a septic appearance (high-output circulatory failure, fever, and mental status changes), although they are abacteremic.…”

Section: Discussionmentioning

confidence: 99%

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Adrenal Dysfunction in Hemodynamically Unstable Patients in the Emergency Department

Rivers

Blake

Dereczyk

et al. 1999

Academic Emergency Medicine

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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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Hypocortisolaemia and adrenocortical responsiveness at onset of septic shock

Abstract: In septic shock, 'hypocortisolaemia' is not uncommon and does not predict a high mortality; adrenocortical hypo-responsiveness may be associated with poor outcome.

Cited by 151 publications

References 32 publications

Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial

Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial

Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock

Adrenal Dysfunction in Hemodynamically Unstable Patients in the Emergency Department

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