Relative Adrenal Insufficiency Among Trauma Patients in a Community Hospital

Abstract

The integrity of the hypothalamic-pituitary-adrenal (HPA) axis is a major determinant of the host response to stress. Recent studies have proven that low doses of hydrocortisone and fludrocortisone can significantly reduce mortality in patients with relative adrenal insufficiency (RAI) without increasing adverse events. This study was a retrospective chart review of patients in a community hospital who carried the diagnosis of both adrenal insufficiency and trauma. Over a 16-month period, the incidence of RAI among severely injured patients (injury severity score >/= 13) was 3%. Only 1 patient had the classic electrolyte findings of adrenal insufficiency, but all had vasopressor-dependent hypotension. Our patients had an average intensive care unit day stay of 37 days and were not tested for RAI on average until day 20 of their intensive care unit stay. Random cortisol levels did not correlate with injury severity. Six patients (75%) had a positive hemodynamic response to steroids. Relative adrenal insufficiency after trauma is rare. In RAI, clear signs and symptoms are usually absent. The clinical diagnostic clue may be the unexplained hypotension and the resistance to inappropriately high doses of inotropes and vasoactive agents. The hemodynamic profile often shows a hyperdynamic state of high cardiac output and a low systemic vascular resistance. Baseline serum cortisol levels did not correlate with injury severity scores in this group of patients, which suggests a defect in the HPA axis. An intensive care unit day stay of greater than or equal to 20 days, ventilator dependence/acute respiratory distress syndrome, and a hyperdynamic state mandates consideration of endocrine testing to exclude RAI. Physiologic doses of hydrocortisone can reverse this potentially life-threatening syndrome.