Hypothalamo-pituitary-adrenal axis activity after intracranial catastrophies: what is enough?

Ab Johan Groeneveld,Albertus Beishuizen,Nienke Molenaar

doi:10.1186/cc7131

Ab Johan Groeneveld, Albertus Beishuizen + Show 1 more

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https://doi.org/10.1186/cc7131

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Journal: Critical Care	Publication Date: Jan 1, 2008
Citations: 4	License type: cc-by

Affiliation: Amsterdam UMC Location VUmc

Abstract

This commentary on a paper by Bendel and colleagues in the previous issue of Critical Care describes the difficulty in assessing the sufficiency of adrenal responses to endogenous, stress-induced adrenocorticotropic hormone (ACTH) release by the pituitary or to exogenous ACTH administration in the critically ill patient in general, and after subarachnoid hemorrhage in particular. It is argued that comparisons with responses under circumstances of equal stress as well as assessments of severity of disease are necessary to judge the sufficiency of cortisol responses to endogenous and exogenous ACTH before treatment is considered. There are no universally applicable cutoff values for cortisol levels – and increases in cortisol levels with increasing levels of ACTH – for the diagnosis of relative adrenal insufficiency (or as it is now commonly termed, critical illnes-related corticosteroid insufficiency) following, for example, subarachnoid hemorrhage or other intracranial catastrophes. The paper by Bendel and colleagues is critically discussed in view of these concepts.

Highlights

The expression ‘enough is enough’ refers to the idea that we can unambiguously decide on what is sufficient in life
We interpret the findings by the authors on the basis of increases in circulating adrenocorticotropic hormone (ACTH), but not of circulating cortisol, with increasing clinical severity of subarachnoid hemorrhage (SAH), and that some adrenal insufficiency is present in severely afflicted patients in the acute phase, compared to controls, even though the study does not allow one to determine whether controls were stressed
Sufficient adaptation to the stress response would be suggested by parallel increases in ACTH and cortisol levels acording to the degree of stress associated with the severity of disease [2,6,7]

Summary

Introduction

The expression ‘enough is enough’ refers to the idea that we can unambiguously decide on what is sufficient in life. We interpret the findings by the authors on the basis of increases in circulating adrenocorticotropic hormone (ACTH), but not of circulating cortisol, with increasing clinical severity of SAH, and that some (relative) adrenal insufficiency is present in severely afflicted patients in the acute phase, compared to controls, even though the study does not allow one to determine whether controls (after aneurysm surgery) were stressed.

Results

Conclusion