Abstract
IntroductionAdrenal failure (AF) is associated with increased mortality in septic patients. Nonetheless, there is no agreement regarding the best diagnostic criteria for AF. We compared the diagnosis of AF considering different baseline total cortisol cutoff values and Δmax values after low (1 μg) and high (249 μg) doses of corticotropin, we analyzed the impact of serum albumin on AF identification and we correlated laboratorial AF with norepinephrine removal.MethodsA prospective noninterventional study was performed in an intensive care unit from May 2002 to May 2005, including septic shock patients over 18 years old without previous steroid usage. After measurement of serum albumin and baseline total cortisol, the patients were sequentially submitted to 1 μg and 249 μg corticotropin tests with a 60-minute interval between doses. Post-stimuli cortisol levels were drawn 60 minutes after each test (cortisol 60 and cortisol 120). The cortisol 60 and cortisol 120 values minus baseline were called Δmax1 and Δmax249, respectively. Adrenal failure was defined as Δmax249 ≤ 9 μg/dl or baseline cortisol ≤ 10 μg/dl. Other baseline cortisol cutoff values referred to as AF in other studies (≤15, ≤20, ≤25 and ≤34 μg/dl) were compared with Δmax249 ≤ 9 μg/dl and serum albumin influence. Norepinephrine removal was compared with the baseline cortisol values and Δmax249 values.ResultsWe enrolled 102 patients (43 male). AF was diagnosed in 22.5% (23/102). Patients with albumin ≤2.5 g/dl presented a lower baseline total cortisol level (15.5 μg/dl vs 22.4 μg/dl, P = 0.04) and a higher frequency of baseline cortisol ≤25 μg/dl (84% vs 58.3%, P = 0.05) than those with albumin > 2.5 g/dl. The Δmax249 levels and Δmax249 ≤ 9, however, were not affected by serum albumin (14.5 μg/dl vs 18.8 μg/dl, P = 0.48 and 24% vs 25%, P = 1.0). Baseline cortisol ≤ 23.6 μg/dl was the most accurate diagnostic threshold to determine norepinephrine removal according to the receiver operating characteristic curve.ConclusionAF was identified in 22.5% of the studied population. Since Δmax249 ≤ 9 μg/dl results were not affected by serum albumin and since the baseline serum total cortisol varied directly with albumin levels, we propose that Δmax249 ≤ 9 μg/dl, which means Δmax after high corticotropin dose may be a better option for AF diagnosis whenever measurement of free cortisol is not available. Baseline cortisol ≤23.6 μg/dl was the best value for predicting norepinephrine removal in patients without corticosteroid treatment.
Highlights
Adrenal failure (AF) is associated with increased mortality in septic patients
Since Δmax249 ≤ 9 μg/dl results were not affected by serum albumin and since the baseline serum total cortisol varied directly with albumin levels, we propose that Δmax249 ≤ 9 μg/dl, which means Δmax after high corticotropin dose may be a better option for adrenal failure (AF) diagnosis whenever measurement of free cortisol is not available
AF failure was identified more reliably by Δmax249 ≤ 9 μg/dl than by several baseline cortisol cutoff values since serum albumin levels directly affected the measurement of the serum total cortisol at baseline and after low and high doses of corticotropin, as well as the frequency of different baseline total cortisol cutoff values; serum albumin levels did not affect the measurement of Δmax levels and the frequency of Δmax249 ≤ 9 μg/ dl
Summary
Adrenal failure (AF) is associated with increased mortality in septic patients. Septic shock and multiple organ failure are the most frequent causes of death in medical intensive care units (ICUs), and were responsible for approximately 750,000 admissions and 210,000 deaths throughout 1995 in the USA [1]. Patients with adrenal failure (AF) and septic shock are known to present high mortality rates [5]. Stress doses of hydrocortisone have been shown to AF = adrenal failure; Δmax = difference between the highest serum cortisol value after corticotropin stimulus and the baseline cortisol value; Δmax1= difference between serum cortisol value after low (1 μg) corticotropin dose and the baseline cortisol value; Δmax249= difference between serum cortisol value after high (249 μg) corticotropin dose and the baseline cortisol value; ICU = intensive care unit
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