Abstract
BackgroundCritical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO.MethodsThis is a prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 h, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (T0) 0.25 mg iv of tetracosactrin and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. CIRCI was defined as T0 < 10 μg/dL (276 nmol/L) and/or Δmax < 9 μg/dL (248 nmol/L) and inadequate adrenal reserve as Δmax < 9 μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation. A competing risk analysis was used to assess extubation failure and mortality.ResultsSeventy-six consecutive patients (63 ± 14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation was significantly decreased in patients with CIRCI or inadequate adrenal reserve, as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI nor with inadequate adrenal reserve.ConclusionCIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO.
Highlights
Critical illness-related corticosteroid insufficiency (CIRCI) was described in intensive care unit (ICU) patients [1], with an impairment of the hypothalamo– pituitary–adrenal (HPA) axis without anatomical lesions.Bagate et al Ann
Because there is no non-invasive consensual definition of Weaning-induced pulmonary oedema (WiPO), we considered three criteria proposed in the recent literature: (i) echocardiographic signs of increased left atrial pressure at the end of the spontaneous breathing trial (SBT): E/A ratio > 0.95 and E/e′ ratio > 8.5 [19]; (ii) an increase of B-type natriuretic peptide (BNP) or NT-proBNP concentration during the SBT [20]; and (iii) an increase of protein concentration during the SBT [21]
We found no association between adrenal function and WiPO, whatever the definition used for adrenal function and for WiPO (Table 3)
Summary
Critical illness-related corticosteroid insufficiency (CIRCI) was described in intensive care unit (ICU) patients [1], with an impairment of the hypothalamo– pituitary–adrenal (HPA) axis without anatomical lesions.Bagate et al Ann. Critical illness-related corticosteroid insufficiency (CIRCI) was described in intensive care unit (ICU) patients [1], with an impairment of the hypothalamo– pituitary–adrenal (HPA) axis without anatomical lesions. Some adrenal profiles derived from corticotropin stimulation test are usually associated with poor outcomes, as alteration of cardiac and vascular functions, prolonged duration of mechanical ventilation (MV) and higher mortality [3, 4]. The aims of this study were to evaluate the prevalence of adrenal insufficiency during difficult weaning from MV, and its possible relation with WiPO. Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality.
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