Abstract
IntroductionAdrenal insufficiency is common in critically ill patients and affects their prognosis, but little is known about how adrenal function changes during prolonged critical illness. This study was conducted to investigate dynamic changes in cortisol levels in patients with critical illness who do not improve after treatment.MethodsThis observational cohort study was performed in the intensive care units of a university hospital. We studied acutely ill patients with initial cortisol level above 34 μg/dl, but who did not improve after treatment and in whom follow-up cortisol levels were determined during critical illness. All clinical information and outcomes were recorded.ResultsFifty-seven patients were included. Ten patients had follow-up cortisol levels above 34 μg/dl, 32 patients had levels between 34 and 15 μg/dl, and 15 patients had levels under 15 μg/dl. Outcomes did not differ significantly among the three groups with different follow-up cortisol levels. In Cox regression analysis, those patients who survived to hospital discharge with second cortisol levels under 15 μg/dl had a longer hospital length of stay (odds ratio = 14.8, 95% confidence interval = 2.4 to 90.0; P = 0.004).ConclusionThe majority of acutely ill patients who remained in a critical condition had decreased serum cortisol levels. Depressed cortisol levels at follow up may lead to worse clinical outcomes. We propose that repeated adrenal function testing be conducted in patients with prolonged critical illness.
Highlights
Adrenal insufficiency is common in critically ill patients and affects their prognosis, but little is known about how adrenal function changes during prolonged critical illness
We studied acutely ill patients with initial cortisol level above 34 μg/dl, but who did not improve after treatment and in whom follow-up cortisol levels were determined during critical illness
The majority of acutely ill patients who remained in a critical condition had decreased serum cortisol levels
Summary
Adrenal insufficiency is common in critically ill patients and affects their prognosis, but little is known about how adrenal function changes during prolonged critical illness. Elevation in corticosteroid level to meet physiological needs during acute illness is a protective response to stress. This homeostasis is maintained by the hypothalamic-pituitary-adrenal (HPA) axis [1,2,3,4,5,6]. Inadequate response as a result of corticosteroid insufficiency is common in critically ill patients, especially those with severe sepsis or septic shock [7,8]. Previous studies have suggested that serum cortisol level below 15 μg/ dl should be regarded as adrenal insufficiency, warranting corticosteroid supplementation [3,14,15,16]. When the diagnosis of adrenal insufficiency is established in acute illness, extended treatment with low-dose hydrocortisone may be required [8]
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