Transient Hypoadrenalism During Surgical Critical Illness

Abstract

Objective: To report the cortisol levels in 6 patients during and after severe inflammation. Design: Patients with severe inflammatory disease had basal and stimulated (cosyntropin) serum cortisol levels determined at the time of severe and less severe inflammation. Setting: Intensive care unit and wards of a tertiary care center. Patients: Six patients with continued evidence of severe inflammation, despite aggressive management of the underlying inflammatory disease. Interventions: Five of 6 patients received hydrocortisone at "physiologic" doses. Main Outcome Measures: Basal and stimulated serum cortisol levels. Results: The mean±SD cortisol data for these patients were as follows: baseline cortisol level during inflammation, 350±121 nmol/L (n=6); stimulated cortisol level during inflammation, 571±326 nmol/L (n=6); baseline cortisol level with less inflammation, 833±339 nmol/L (P=.03 vs baseline level during inflammation) (n=5); and stimulated cortisol level with less inflammation, 1090±295 nmol/L (P=.03 vs stimulated level during inflammation) (n=4). Manifestations of inflammation decreased with hydrocortisone administration. Conclusions: Severe inflammation may result in lowerthan-expected serum cortisol levels, which then increase significantly as the inflammation decreases. Transient hypoadrenalism may aggravate the adverse effects of severe inflammation. These effects may be ameliorated by administering physiologic rather than pharmacologic doses of hydrocortisone.

Adrenal Response to Adrenocorticotropic Hormone in Dogs before and after Surgical Attenuation of a Single Congenital Portosystemic Shunt

“…36 Unlike our patients, however, humans with transient postsurgical hypoadrenalism had severe inflammation and sepsis, and their baseline cortisol concentrations increased as inflammation decreased. 36 Because cortisol concentrations in dogs are much lower than in humans, applying criteria of inadequate adrenal function from the human literature is inappropriate. We therefore evaluated adrenal function based on previously published criteria ( 30 ng/mL increase over baseline) for septic dogs 10 and by using a relatively conservative estimate of 50% increase in post-ACTH cortisol over baseline.…”

“…The most common objective criterion for diagnosis of RAI in humans is post‐ACTH cortisol concentration <180 ng/mL or change in cortisol concentration <90 ng/mL 11 . Treatment with hydrocortisone has also been recommended for humans with transient postsurgical hypoadrenalism when post‐ACTH concentrations did not double 36 . Unlike our patients, however, humans with transient postsurgical hypoadrenalism had severe inflammation and sepsis, and their baseline cortisol concentrations increased as inflammation decreased 36 .…”

“…Treatment with hydrocortisone has also been recommended for humans with transient postsurgical hypoadrenalism when post‐ACTH concentrations did not double 36 . Unlike our patients, however, humans with transient postsurgical hypoadrenalism had severe inflammation and sepsis, and their baseline cortisol concentrations increased as inflammation decreased 36 . Because cortisol concentrations in dogs are much lower than in humans, applying criteria of inadequate adrenal function from the human literature is inappropriate.…”

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

“…Serum cortisols and their response to ACTH are sometimes attenuated in severe inflammatory conditions or septic shock. 12,21 For those patients who survive their critical illness, adrenal function usually normalizes. In some studies supplemental glucocorticoids are supplied, and in others they are not.…”

Adrenal Insufficiency Overview

“…But it was found that in most cases of adrenal infiltration with malignant cells still residual adrenal tissue is capable of maintaining needs even with stress [21,24]; chronic infections such as Fungal infection e.g. histoplasmosis and paracoccidiomycosis in endemic areas [25]. And others such as syphilis and African trypanosomiasis.…”