cosyntropin and Critical-Illness

In the last two decades there was important evolution on the knowledge of the function of the hypothalamic-pituitary-adrenal axis. In the last decade, the expression "relative adrenal insufficiency" (RAI) was created, and more recently "critical illness-related corticosteroid insufficiency" (CIRCI) was used to designate those patients in which cortisol production was not sufficiently increased in stress situations. Patients with CIRCI have elevated hospital morbidity and mortality. Currently, there is a wide discussion about diagnostic criteria for this dysfunction. Besides basal cortisol, some publications now study the role of other tests, such as cortrosyn test - either in low (1 μg) or high doses (250 μg); free cortisol, salivary cortisol, metyrapone test and others. With this review, we aimed at summarizing the results of the most influent papers that intended to define diagnostic criteria for CIRCI. We also suggest an approach for CIRCI diagnosis and make it clear that the decision about steroid therapy in septic shock patients is matter apart from RAI.

Topics: Adrenal Insufficiency; Adrenocorticotropic Hormone; Arginine Vasopressin; Corticotropin-Releasing Hormone; Cosyntropin; Critical Care; Critical Illness; Humans; Hydrocortisone; Metyrapone; Pituitary Gland; Steroids

This article will review the clinical presentation, diagnosis, and treatment of acute adrenal insufficiency and explore the concept of 'relative adrenal insufficiency' in the critically ill.. Current dogma suggests that as many as 70% of patients in intensive care units with the clinical syndromes of sepsis or cardiogenic shock have 'relative adrenal insufficiency'. This article will explore how this concept came into being and why the concept has no clinical utility.. This article will provide an approach to critically ill patients that will identify adrenal insufficiency when it is part of the pathophysiology of a given patient and, at the same time, prevent the unnecessary treatment of critically ill patients with high doses of glucocorticoids for 'stress' when adrenal insufficiency is not a factor in the illness.

Topics: Adrenal Glands; Adrenal Insufficiency; Cosyntropin; Critical Illness; Humans; Hydrocortisone; Pituitary-Adrenal Function Tests; Stress, Psychological

To evaluate the utility of cosyntropin 1 microg in assessing adrenal function in critically ill patients.. A computerized literature search using MEDLINE, EMBASE, International Pharmaceutical Abstracts, and the Cochrane Database (1966-August 2004) was undertaken for trials evaluating cosyntropin 1 mug using the following search terms: adrenocorticotropin-releasing hormone (ACTH), cosyntropin, adrenal insufficiency, cortisol, corticosteroids, glucocorticoids, sepsis, septic shock, diagnosis, critically ill, intensive care, and critical care. STUDY SELECTION AND DATA SYNTHESIS: Identifying patients with sepsis with relative adrenal insufficiency (AI) using cosyntropin testing may identify those likely to benefit from corticosteroids. The results of 5 heterogeneous studies in non-intensive care unit (ICU) patients suggest that both 1 microg and 250 microg of cosyntropin stimulate similar cortisol responses and that testing using both doses correlates well with results from insulin tolerance testing. Some data from non-ICU patients suggest that the 1-microg test may be more sensitive to detect AI; 3 heterogeneous studies in ICU patients confirmed the improved sensitivity of the 1-microg test.. Use of cosyntropin 1 microg should detect AI in all patients who would have been diagnosed using 250 microg. Unfortunately, all of the clinical trials evaluating the role of corticosteroids in septic shock that used the cosyntropin stimulation test administered 250 microg. Extrapolation of the existing guidelines to treat patients with septic shock testing positive for relative AI using the 1-microg test may provide effective therapy to appropriate patients not diagnosed by the 250-microg testing or may introduce additional adverse effects in patients who should not receive corticosteroids. Large-scale, head-to-head comparison data of steroid effectiveness after 1- and 250-microg ACTH stimulation tests are needed to expand upon these promising results.

Topics: Adrenal Insufficiency; Cosyntropin; Critical Illness; Humans

Although the true incidence of adrenal insufficiency in critically ill patients is unknown, there is evidence that even partial adrenal insufficiency in such patients is associated with increased mortality. But exactly how should adrenal insufficiency be defined and diagnosed, and who should receive treatment?

Topics: Adrenal Insufficiency; Algorithms; Cosyntropin; Critical Care; Critical Illness; Humans; Practice Guidelines as Topic

Topics: Acute Disease; Adrenal Cortex Hormones; Adrenal Insufficiency; Cosyntropin; Critical Illness; Glucocorticoids; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Pituitary-Adrenal System; Shock, Septic

To investigate adrenocortical function in patients with ruptured aneurysm of the abdominal aorta.. Prospective clinical investigation.. Surgical intensive care unit in a university teaching hospital and intensive care unit in a general hospital.. 54 patients with a documented rupture of the abdominal aorta.. A short adrenocorticotrophic hormone (ACTH) stimulation test was performed.. Patients were studied within 24 h of admission to the hospital. Blood samples for the measurement of cortisol and ACTH were collected at 0800 h. Subsequently 0.25 mg tetracosactrin (Synacthen) was injected i.v. and after 60 min cortisol measurement was repeated. The criterion for a normal short ACTH test was: stimulated or unstimulated cortisol levels > or = 0.55 mumol/l. For the group as a whole, an unstimulated plasma cortisol level of 0.76 mumol/l was comparable to that in other groups of critically ill patients with similar severity of illness. Between survivors and non survivors, significant differences were found between unstimulated plasma cortisol levels (0.70 vs 1.03 mumol/l), stimulated plasma cortisol levels (1.00 vs 1.30 mumol/l), and plasma ACTH levels (72 vs 133 ng/l). One patient did not meet the criteria for normal adrenocortical function: unstimulated plasma cortisol 0.26 mumol/l, stimulated plasma cortisol 0.47 mumol/l.. In the patients studied with ruptured aneurysm of the abdominal aorta, adrenocortical response was comparable to that in other groups of critically ill patients with similar severity of illness. High cortisol levels were associated with mortality. One patient did not meet the criteria for normal adrenocortical function but survival without steroid treatment.

Topics: Adrenal Insufficiency; Adrenocorticotropic Hormone; Aged; Aged, 80 and over; Anesthetics, Intravenous; Aorta, Abdominal; Aortic Rupture; APACHE; Cosyntropin; Critical Illness; Etomidate; Female; Hormones; Humans; Hydrocortisone; Male; Middle Aged; Postoperative Complications; Prospective Studies

Cardiogenic shock shares with septic shock common hemodynamic features, inflammatory patterns, and most likely similar complications such as critical illness-related corticosteroid insufficiency. The aim of this study was to evaluate the prevalence of critical illness-related corticosteroid insufficiency in cardiogenic shock patients and to secondarily assess its prognostic value on 90-day mortality.. A single-center prospective observational study conducted over a 3-year period and including all patients with cardiogenic shock. Main exclusion criteria were patients with prior cardiac arrest, sepsis, ongoing corticosteroid therapy, and etomidate administration. A short corticotropin test was performed in the first 24 h following admission. Serum cortisol levels were measured before (T0) and 60 min (T60) after administration of 250 μg of cosyntropin. Critical illness-related corticosteroid insufficiency was defined according to the 2017 consensus definition (basal total cortisol<10 μg·dL or a delta cortisol T60-T0<9 μg·dL) as well as the thresholds published in 2016 in cardiogenic shock patients associated with worst prognosis (basal total cortisol>29 μg·dL and delta cortisol T60-T0<17 μg·dL).. Seventy-nine consecutive patients hospitalized in intensive care for cardiogenic shock met the inclusion criteria. Overall mortality was 43% at day 90. Forty-two percent had critical illness-related corticosteroid insufficiency using the 2017 consensus definition and 32% using the 2016 cardiogenic shock thresholds. Presence of critical illness-related corticosteroid insufficiency was not an independent factor associated with 90-day mortality irrespective of the thresholds used.. Critical illness-related corticosteroid insufficiency is a frequent occurrence in medical cardiogenic shock. However, in this study, such insufficiency was not associated with prognosis.

Topics: Adrenal Cortex Hormones; Aged; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Male; Middle Aged; Prospective Studies; Sepsis; Shock, Cardiogenic

Cortisol clearance is reduced in sepsis and may contribute to the development of impaired adrenocortical function that is thought to contribute to the pathophysiology of critical illness-related corticosteroid insufficiency. We sought to assess adrenocortical function using computer-assisted numerical modeling methodology to characterize and compare maximal cortisol secretion rate and free cortisol half-life in septic shock, sepsis, and healthy control subjects.. Post hoc analysis of previously published total cortisol, free cortisol, corticosteroid-binding globulin, and albumin concentration data.. Single academic medical center.. Subjects included septic shock (n = 45), sepsis (n = 25), and healthy controls (n = 10).. I.v. cosyntropin (250 μg).. Solutions for maximal cortisol secretion rate and free cortisol half-life were obtained by least squares solution of simultaneous, nonlinear differential equations that account for free cortisol appearance and elimination as well as reversible binding to corticosteroid-binding globulin and albumin. Maximal cortisol secretion rate was significantly greater in septic shock (0.83 nM/s [0.44, 1.58 nM/s] reported as median [lower quartile, upper quartile]) compared with sepsis (0.51 nM/s [0.36, 0.62 nM/s]; p = 0.007) and controls (0.49 nM/s [0.42, 0.62 nM/s]; p = 0.04). The variance of maximal cortisol secretion rate in septic shock was also greater than that of sepsis or control groups (F test, p < 0.001). Free cortisol half-life was significantly increased in septic shock (4.6 min [2.2, 6.3 min]) and sepsis (3.0 min [2.3, 4.8 min] when compared with controls (2.0 min [1.2, 2.6 min]) (both p < 0.004).. Results obtained by numerical modeling are consistent with comparable measures obtained by the gold standard stable isotope dilution method. Septic shock is associated with generally not only higher levels but also greater variance of maximal cortisol secretion rate when compared with control and sepsis groups. Additional studies would be needed to determine whether assessment of cortisol kinetic parameters such as maximal cortisol secretion rate and free cortisol half-life is useful in the diagnosis or management of critical illness-related corticosteroid insufficiency.

Topics: Academic Medical Centers; Adrenal Cortex; Adult; Aged; Aged, 80 and over; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Male; Middle Aged; Sepsis; Serum Albumin; Shock, Septic; Transcortin

Critically ill cancer patients with sepsis represent a high-risk sub-group for the development of critical illness-related corticosteroid insufficiency (CIRCI); however, the incidence of CIRCI in this population is unknown. The purpose of this study was to determine the incidence of CIRCI in cancer patients with severe sepsis or septic shock.. A single-center, retrospective, observational study was conducted in a 52-bed medical-surgical intensive care unit of a National Cancer Institute-recognized academic oncology institution. Eighty-six consecutive patients with a diagnosis of severe sepsis or septic shock who received a high-dose 250-μg cosyntropin stimulation test were included. CIRCI was identified by a maximum delta serum cortisol of 9 μg/dL or less post cosyntropin.. Overall, 59% (95% CI, 48-70%) of cancer patients with severe sepsis or septic shock were determined to have CIRCI. When compared to patients without CIRCI, patients with CIRCI had higher baseline serum cortisol (median, 26.3 versus 14.7 μg/dL; p = 0.002) and lower delta cortisol levels (median, 3.1 versus 12.5 μg/dL; p < 0.001). Mortality did not differ between the two groups. An inverse relationship was identified between baseline serum cortisol and maximum delta cortisol (maximum delta cortisol = -0.27 × baseline cortisol + 14.30; R (2) = 0.208, p < 0.001).. The incidence of CIRCI in cancer patients with severe sepsis or septic shock appears high. Further large-scale prospective trials are needed to confirm these findings.

Topics: Adrenal Insufficiency; Adult; Aged; Aged, 80 and over; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Incidence; Male; Middle Aged; Retrospective Studies; Sepsis; Severity of Illness Index; Shock, Septic; Young Adult

The pathophysiology of adrenal insufficiency, common in surgical intensive care units, has not been fully elucidated.. Patients at risk (age > 55 years, in the surgical intensive care unit >1 week, baseline cortisol < 20 μg/dL) were enrolled. After measuring cortisol and adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH) was administered. ACTH and cortisol were measured over 120 minutes. Short and long cosyntropin stimulation tests determined adrenal function. Area under the curve (AUC) and mixed linear models were used to compare cortisol and ACTH responses. Patients were grouped according to survival and response to stimulation testing. Chi-square and t tests were performed, and P values < .05 were considered statistically significant.. Six of 25 patients responded poorly to cosyntropin, and 5 died compared with 3 after a normal response (P < .01). ACTH (AUC) and ACTH peak were increased in nonsurvivors after CRH administration. Cortisol peak and AUC were not different.. ACTH responsiveness was increased in nonsurvivors and may predict mortality.

Topics: Adrenal Insufficiency; Adrenocorticotropic Hormone; Aged; Aged, 80 and over; Area Under Curve; Corticotropin-Releasing Hormone; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Intensive Care Units; Linear Models; Male; Middle Aged; Pituitary-Adrenal System; Postoperative Complications; Prognosis

In critical illness, serum total cortisol (TC) may not adequately reflect adrenal function because of reduced cortisol-binding globulin (CBG).. To evaluate adrenal function of critically ill children, using free cortisol index (FCI), calculated free cortisol (cFC), and TC levels.. Thirty-two critically ill and 36 healthy children were included. All children underwent the 1 microg cosyntropin test. TC and CBG levels were measured. Basal and peak TC, FCI, and cFC were determined.. Basal and peak TC, FCI, and cFC of critically ill children were significantly higher than those of the controls. Compared with TC, both basal and peak FCI and cFC of the patients were higher than those of controls to a greater degree. Use of FCI or cFC to diagnose adrenal insufficiency (AI) reduced the frequency of diagnosis of AI by 50%.. FCI and cFC better reflect the dynamic changes of adrenal function of critically ill children.

Topics: Adolescent; Carrier Proteins; Child; Child, Preschool; Cohort Studies; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Infant; Intensive Care Units, Pediatric; Male; Pituitary-Adrenal System; Prospective Studies; Thailand

Topics: Adrenal Insufficiency; Aged; Cosyntropin; Critical Illness; Female; Humans; Male; Middle Aged; Retrospective Studies; Shock, Septic

Baseline and cosyntropin-stimulated serum (total and free) and salivary cortisol concentrations were measured, in the early afternoon, in 51 critically ill patients and healthy subjects. Patients were stratified according to their serum albumin at the time of testing: those whose serum albumin levels were 2.5 gm/dl or less vs. others whose levels were greater than 2.5 gm/dl.. Baseline and cosyntropin-stimulated serum free cortisol levels were similar in the two groups of critically ill patients and were severalfold higher (P < 0.001) than those of healthy subjects. Similarly, baseline and cosyntropin-stimulated salivary cortisol concentrations were equally elevated in the two critically ill patient groups and were severalfold higher (P < 0.001) than those of healthy subjects. Salivary cortisol concentrations correlated well with the measured serum free cortisol levels.. Salivary cortisol measurements are simple to obtain, easy to measure in most laboratories, and provide an indirect yet reliable and practical assessment of the serum free cortisol concentrations during critical illnesses. The concentrations of the two measures of unbound cortisol determined in two different body fluids correlated very well, regardless of the serum protein concentrations. Measurements of salivary cortisol can serve as a surrogate marker for the free cortisol in the circulation.

Topics: Adrenal Cortex Function Tests; Adrenocorticotropic Hormone; Aged; Biomarkers; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Male; Middle Aged; Saliva; Serum Albumin

Because more than 90 percent of circulating cortisol in human serum is protein-bound, changes in the binding proteins can alter measured serum total cortisol concentrations without influencing free concentrations of this hormone. We investigated the effect of decreased amounts of cortisol-binding proteins on serum total and free cortisol concentrations during critical illness, when glucocorticoid secretion is maximally stimulated.. Base-line serum total cortisol, cosyntropin-stimulated serum total cortisol, aldosterone, and free cortisol concentrations were measured in 66 critically ill patients and 33 healthy volunteers in groups that were similar with regard to sex and age. Of the 66 patients, 36 had hypoproteinemia (albumin concentration, 2.5 g per deciliter or less), and 30 had near-normal serum albumin concentrations (above 2.5 g per deciliter).. Base-line and cosyntropin-stimulated serum total cortisol concentrations were lower in the patients with hypoproteinemia than in those with near-normal serum albumin concentrations (P<0.001). However, the mean (+/-SD) base-line serum free cortisol concentrations were similar in the two groups of patients (5.1+/-4.1 and 5.2+/-3.5 microg per deciliter [140.7+/-113.1 and 143.5+/-96.6 nmol per liter]) and were several times higher than the values in controls (0.6+/-0.3 microg per deciliter [16.6+/-8.3 nmol per liter], P<0.001 for both comparisons). Cosyntropin-stimulated serum total cortisol concentrations were subnormal (18.5 microg per deciliter [510.4 nmol per liter] or less) in 14 of the patients, all of whom had hypoproteinemia. In all 66 patients, including these 14 who had hypoproteinemia, the base-line and cosyntropin-stimulated serum free cortisol concentrations were high-normal or elevated.. During critical illness, glucocorticoid secretion markedly increases, but the increase is not discernible when only the serum total cortisol concentration is measured. In this study, nearly 40 percent of critically ill patients with hypoproteinemia had subnormal serum total cortisol concentrations, even though their adrenal function was normal. Measuring serum free cortisol concentrations in critically ill patients with hypoproteinemia may help prevent the unnecessary use of glucocorticoid therapy.

Topics: Adrenal Insufficiency; Adrenocorticotropic Hormone; Aged; Aldosterone; APACHE; Cosyntropin; Critical Illness; Humans; Hydrocortisone; Hypoalbuminemia; Hypoproteinemia; Middle Aged; Pituitary-Adrenal System; Regression Analysis

Topics: Adrenal Cortex Hormones; Cosyntropin; Critical Illness; Humans; Hydrocortisone; Hypoproteinemia; Sensitivity and Specificity; Shock, Septic

We hypothesized that hypothyroidism and adrenal insufficiency frequently occur together in critically ill patients.. A prospective observational study.. Surgical intensive care unit of a university-affiliated tertiary referral center.. Sixty-six consecutive patients with severe sepsis, septic shock, and hemorrhagic shock who required pulmonary artery catheterization for resuscitation were studied.. Thyrotropin and baseline cortisol levels were obtained at 3 am followed by intravenous injection of 250 mug of cosyntropin, a synthetic adrenocorticotropic hormone derivative. A second measurement of the cortisol level was performed 1 hour later.. Incidence of hypothyroidism and adrenal insufficiency and mortality.. Mean (SD) age was 62 (19) years. The mean (SD) Acute Physiology and Chronic Health Evaluation II score was 21 (5). Twenty-seven patients (40.9%) had severe sepsis, 31 (46.9%) had septic shock, and 8 (12.1%) had hemorrhagic shock. Five patients (7.6%) had hypothyroidism alone and 35 (53.0%) had only adrenal insufficiency. Eight patients (12.1%) had both hypothyroidism and adrenal insufficiency. All patients with endocrine abnormalities were treated. Mortality for the total group was 15 (22.7%) of 66 patients.. There is a 12% incidence of simultaneous hypothyroidism and adrenal insufficiency in our study and the routine testing for both may be indicated in this population of critically ill patients.

Topics: Adrenal Insufficiency; Adrenocorticotropic Hormone; Aged; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Hypothyroidism; Incidence; Injections, Intravenous; Male; Middle Aged; Prospective Studies; Sepsis; Shock, Hemorrhagic; Shock, Septic; Thyrotropin; Wounds and Injuries

To examine the incidence and response to treatment of adrenal insufficiency (AI) in high-risk postoperative patients.. Prospective observational case series.. Large urban tertiary-care surgical ICU (SICU).. Adults > 55 years of age who required vasopressor therapy after adequate volume resuscitation in the immediate postoperative period.. Each patient underwent a cosyntropin (ACTH) stimulation test; at the discretion of the clinical team, some patients were empirically given hydrocortisone (100 mg IV q8h for three doses) before serum cortisol values became available.. Adrenal dysfunction (AD), defined as serum cortisol < 20 microg/dL at all time points, with Delta cortisol (60 min post-ACTH minus baseline) of < or = 9 microg/dL; functional hypoadrenalism (FH), defined as serum cortisol < 30 microg/dL at all time points or Delta cortisol (60 min post-ACTH minus baseline) < or = 9 microg/dL; and AI, as the presence of either AD or FH.. One hundred four patients were enrolled with a mean age (SD) of 65.2 +/- 16.9 years. AI (AD plus FH) was found in 34 of 104 patients (32.7%): AD was found in 9 patients (8.7%), FH in 25 patients (24%), and normal adrenal function in 70 patients (67.3%). The absolute eosinophil count was significantly higher in the combined AD and FH groups compared with the group with normal adrenal function (p < 0.05). Forty-six of 104 patients (44.2%) received hydrocortisone; 29 (63%) could be weaned from treatment with vasopressors within 24 h. This beneficial effect of hydrocortisone reached statistical significance in the FH group when compared with untreated patients (p < 0.031); a similar trend was seen in the AD group (p = 0.083). Mortality was also lower in the hydrocortisone-treated AI patients (5 of 23 [21%] vs 5 of 11 [45%] in those not receiving hydrocortisone; p < 0.01).. There is a high incidence of AI among SICU patients > 55 years of age with postoperative hypotension requiring vasopressors. There is also a significant association between hydrocortisone replacement therapy, resolution of vasopressor requirements, and improved survival.

Topics: Adrenal Insufficiency; Aged; Cosyntropin; Critical Illness; Female; Humans; Hydrocortisone; Hypotension; Incidence; Intensive Care Units; Male; Middle Aged; Postoperative Complications; Prospective Studies; Risk Factors; Vasoconstrictor Agents

Whereas the antifungal azole ketoconazole interferes with steroidogenesis and can cause adrenal insufficiency, fluconazole in standard doses is thought to not interfere with cortisol production. The objective was to evaluate the effect of high-dose fluconazole therapy on adrenal function in critically ill patients in an intensive care setting.. Descriptive case reports.. Medical intensive care unit in a university hospital.. Two patients, a 77-yr-old man (case 1) with esophageal cancer and a 66-yr-old woman (case 2) with multiple organ failure developed reversible adrenal insufficiency temporally related to the institution and withdrawal of high-dose fluconazole.. Short cosyntropin (adrenocorticotropic hormone; ACTH) stimulation tests.. Two days after high-dose fluconazole in case 1, the serum ACTH level was 121 pg/mL (normal range is 9-52 pg/mL), and the peak cortisol after ACTH stimulation was 15.5 microg/dL (normal response is >or=18 microg/dL). Eleven days after discontinuation of fluconazole, the peak cortisol level after ACTH stimulation was 43.4 microg/dL. Twenty-four hours after high-dose fluconazole in case 2, an ACTH stimulation test had a low peak serum cortisol of 16.8 microg/dL. Fluconazole was withdrawn, and 5 days later, the peak stimulated cortisol was 20.6 microg/dL.. Although fluconazole is the therapy of choice for patients in the intensive care setting with Candida infections, two patients with multiple organ failure who received high-dose fluconazole appeared to develop adrenal insufficiency. Although preliminary and anecdotal, these data suggest a need to further investigate the possibility that high-dose fluconazole might cause adrenal insufficiency in already compromised critically ill patients.

Topics: Adrenal Insufficiency; Adrenocorticotropic Hormone; Aged; Antifungal Agents; Candidiasis; Cosyntropin; Critical Care; Critical Illness; Fatal Outcome; Female; Fluconazole; Humans; Hydrocortisone; Male; Multiple Organ Failure; Patient Selection; Time Factors

Many patients with acquired immune deficiency syndrome (AIDS) have symptoms consistent with adrenal insufficiency, but only a small subset of these patients meet criteria for adrenal insufficiency during a short corticotropin (ACTH) stimulation test. We hypothesized that patients with AIDS and symptoms of adrenal insufficiency who produce normal amounts of cortisol in response to administration of 0.25 mg cosyntropin may nevertheless produce lower amounts of cortisol in a course of 24 hours than comparably sick AIDS patients without symptoms of adrenal insufficiency or comparably sick patients without AIDS. We studied four groups of male patients: AIDS patients with symptoms suggestive of adrenal insufficiency but with a normal response to cosyntropin (group I), AIDS patients without symptoms suggestive of adrenal insufficiency (group II), human immunodeficiency virus (HIV)-negative patients with serious acute or chronic illness (group III), and healthy subjects (group IV). The following variables were examined: age, CD4 cell count, Acute Physiologic and Chronic Health Evaluation (APACHE) score, serum cortisol and plasma ACTH at baseline; serum cortisol at 30 and 60 minutes after intravenous administration of 0.25 mg cosyntropin; and 24-hour urinary free cortisol. The four groups had a similar mean age and baseline plasma ACTH and serum cortisol levels. However, a change in cortisol from baseline to 30 and 60 minutes after administration of cosyntropin was significantly smaller in both groups of AIDS patients than in the sick patients without AIDS and normal subjects. There were also differences noted between the two groups of AIDS patients: both baseline and stimulated levels of cortisol tended to correlate directly with ACTH levels in patients without symptoms of adrenal insufficiency, while this relationship appeared to be inverse in patients with symptoms suggestive of adrenal insufficiency (r = -.57 to -.7, P < .05 to .14). The 24-hour urinary free cortisol levels were similar among all groups, but correlated strongly with baseline and stimulated serum cortisol levels only in patients with AIDS and symptoms of adrenal insufficiency (r = .8 to .9, P < .002 to .015). We conclude that (1) AIDS patients with and without symptoms of adrenal insufficiency may have either normal adrenal function or somewhat suboptimal adrenal reserve as demonstrated by a blunted cortisol response during the short ACTH stimulation test in comparison to HIV-negative comparabl

Topics: Acquired Immunodeficiency Syndrome; Adrenal Gland Diseases; Adrenocorticotropic Hormone; Adult; Circadian Rhythm; Cosyntropin; Critical Illness; HIV Seronegativity; Humans; Hydrocortisone; Male; Reference Values

We describe three critically ill patients who displayed indirect evidence of transient corticotropin deficiency. All these patients were elderly, were poorly nourished, and had unexplained hypotension intraoperatively or immediately postoperatively. During the hypotensive episodes, they had inappropriately low plasma cortisol levels (10, 12, and 6 micrograms/dl) and responded dramatically to the administration of glucocorticoids. A normal response to infusion of synthetic corticotropin excluded primary adrenal insufficiency. Two patients tested had low thyroxine levels without increased thyrotropin concentrations and depressed levels of gonadotropins. In all three patients, the dose of glucocorticoids was successfully tapered and then discontinued. After recovery, serum thyroxine levels increased, gonadotropins reverted to normal concentrations, and the administration of metyrapone to two patients demonstrated normal hypothalamic-pituitary-adrenal function. Cortisol levels of less than 15 micrograms/dl in critically ill patients suggest the presence of adrenal insufficiency. The infusion of synthetic corticotropin may not exclude adrenal insufficiency attributable to corticotropin deficiency. If direct tests of corticotropin reserve are impractical, treatment with glucocorticoids is warranted.

Topics: Adrenocorticotropic Hormone; Aged; Cosyntropin; Critical Illness; Dexamethasone; Female; Humans; Hydrocortisone; Hypotension; Male; Middle Aged

No clear criteria exist to rule out hypoadrenal shock by cosyntropin (alpha 1-24-corticotropin, a synthetic subunit of adrenocorticotropic hormone) testing in persons who have critical nonadrenal illness. Four patients in the surgical intensive care unit with critical multisystem disease and refractory high cardiac output, low vascular resistance shock had significantly diminished or terminated vasopressor requirements after institution of hydrocortisone sodium succinate infusion in doses simulating physiologic stress response (100 to 300 mg of hydrocortisone per day). In each case, cosyntropin testing revealed serum cortisol levels higher than those usually associated with hypoadrenal shock. Positive response was defined as maintenance of blood pressure with a decrease to less than 25% of baseline pressor requirements within 48 hours of treatment. We hypothesize a syndrome of functional hypoadrenalism in patients with multisystem critical illness and refractory shock responsive to glucocorticoid administration in doses simulating physiologic stress response despite cosyntropin stimulation test results that would rule out hypoadrenalism in a normal person.

Topics: Adrenal Cortex Function Tests; Adrenal Insufficiency; Cosyntropin; Critical Illness; Humans; Hydrocortisone; Male; Middle Aged; Shock