Suspected Adrenal Insufficiency in Critically Ill Burned Patients

Abstract

Adrenal insufficiency (AI), whether etomidate-induced or secondary to critical illness-related corticosteroid insufficiency (CIRCI), is a common and under appreciated problem in the intensive care unit intensive care unit (ICU). However, AI is often difficult to identify and diagnose in the critically ill. The pathophysiology and ideal management of etomidate-induced AI and CIRCI, especially in burn patients, is unknown. Many studies, however, have examined the prevalence of and risk factors for developing AI in critically ill populations as well as the effect of AI on morbidity and mortality. Observing a seemingly increased number of patients with suspected AI in our burn ICU, we sought to evaluate and summarize the current literature relating to adrenal insufficiency in the critically ill. We performed an electronic literature search on the PubMed and Ovid Medline databases using the key words "etomidate," "adrenal insufficiency," "CIRCI," and "burn injury." Relevant studies from the current burn and ICU era were selected to be included in this review of the literature. Among the critically ill, burn patients are at increased risk for developing adrenal insufficiency and the risk is greatest for elderly patients with large burns and inhalation injury. Both CIRCI and etomidate-induced AI are associated with high morbidity and mortality, therefore avoiding preventable causes of AI, such as choosing alternatives to etomidate for rapid sequence intubation (RSI) in the severely burn injured patient should be encouraged. Further research is indicated to investigate the biological relationship between AI and associated morbidity and mortality, whether etomidate-induced or secondary to critical illness; as well as how best to identify and diagnose patients with suspected adrenal insufficiency in the burn intensive care unit.

Combined Use of Etomidate and Dexmedetomidine Produces an Additive Effect in Inhibiting the Secretion of Human Adrenocortical Hormones

“…In 1983, Ledingham and 2 other research groups [ 1 ] found that ETO had the effect of inhibiting the synthesis and release of human adrenocortical hormones. Other researchers [ 2 – 6 ] found that the peak effect of ETO in inhibiting the adrenocortical function was 6–8 h after a single-dose injection of ETO, and restored to normal limits spontaneously within 24 h. Continuous injection of ETO could prolong this inhibitory effect beyond 24 h.…”

The Magical Role of Vitamin C on Adrenal Insufficiency Subsequent to Etomidate Administration: Ongoing Challenges in the Management of Trauma Patients

“…Adrenal insufficiency, whether caused by etomidate or secondary to corticosteroid insufficiency associated with critical illness, is a common problem in the intensive care unit. 8 Studies have demonstrated that nearly 50% of critically ill patients (e.g., those with traumatic brain injury) have adrenal insufficiency, which is associated with age, the severity of the injury, and the administration of etomidate. High doses of cortisol should not be prescribed in severe sepsis.…”