62 - Adrenocortical insufficiency in critical illness

Abstract

Dysfunction of the hypothalamo-pituitary adrenal axis has become a central feature in descriptions of the pathophysiology of sepsis and critical illness. Changes in glucocorticoid secretion and responsiveness, protein binding, and activity have been reported. These changes have been described by the terms ‘relative adrenal insufficiency’, or ‘critical illness related corticosteroid insufficiency’, and form part of the rationale for trials of glucocorticoid treatment in septic shock. However, despite hundreds of published articles, including literature reviews and consensus statements, controversy still exists regarding the fundamental nature of the disorder and its relevance to clinical management. The role of steroid supplementation in critical illness continues to be debated. This chapter attempts to establish a critical reappraisal of the evidence for adrenal dysfunction in critical illness, and explores the indications for corticosteroid supplementation in the management of a number of critical illnesses with special emphasis on sepsis and septic shock.