cosyntropin and Emergencies

To assess adrenocortical function following intravenous etomidate use in emergency department (ED) patients requiring intubation.. This was a prospective, randomized, controlled trial of consecutive patients presenting to the ED requiring intubation. Patients were randomized to receive a single bolus induction dose of either 0.05-0.1 mg/kg midazolam (control group) or 0.3 mg/kg etomidate (etomidate group) during a standardized rapid-sequence intubation (RSI) with succinylcholine. The primary outcome variable was adrenocortical function at 4, 12, and 24 hours post-induction as assessed by measured serum cortisol response to exogenous cosyntropin (cosyntropin stimulation test, CST). Fisher's exact test was used to compare CST results between groups.. Thirty-one patients were enrolled: 8 control, 10 etomidate, and 13 excluded from analysis for either incomplete data or steroid use during the study period. The 4-hour CST results were significantly different between study groups, with a normal response in 100% of control patients vs 30% of etomidate patients (p = 0.004). The 12- and 24-hour CSTs did not differ significantly between groups: normal CST in 100% of control patients at 12 and 24 hours vs 100% and 90% among etomidate patients at 12 and 24 hours, respectively (p = 1.0 at 12 and 24 hours). Measured cortisol levels of patients with abnormal CSTs remained within normal laboratory reference ranges.. Use of etomidate in ED patients requiring RSI results in adrenocortical dysfunction. However, cortisol levels remain within normal laboratory levels during this period of dysfunction. Adrenocortical dysfunction appears to resolve within 12 hours of a single bolus dose of 0.3 mg/kg etomidate.

Topics: Adrenal Cortex; Aged; Anesthetics, Intravenous; Cosyntropin; Emergencies; Emergency Service, Hospital; Etomidate; Female; Humans; Hydrocortisone; Injections, Intravenous; Intubation, Intratracheal; Male; Midazolam; Middle Aged

Relative adrenal insufficiency (RAI) is a common complication during septic shock and may be more frequent in specific subgroups. The main objectives of this study were to determine the adrenal function and the RAI incidence in different subgroups of septic shock patients considering: main admission categories (medical, elective or emergency surgery); source of infection; nosocomial or community-acquired infections; gender, age <65 years or >65 years; and the presence or absence of neurological diseases, acute respiratory distress syndrome (ARDS) and bacteremia.. Prospective study in a medical-surgical ICU, including adults with septic shock, from May 2002 to May 2005. All patients had total serum cortisol measured at baseline and 60 min after a high-dose ACTH test within the first 96 h of shock onset. RAI was defined as a serum cortisol increment after ACTH test (Deltamax(249)) <90 microg/l.. One hundred and two subjects were enrolled, and the overall RAI incidence was 22.5%. Patients with ARDS before ACTH test or bacteremia showed lower Deltamax(249) values than patients with ARDS after ACTH test (96 vs. 153 microg/l, P=0.02) or without bacteremia (140 vs. 175 microg/l, P=0.04). Multivariate regression analysis revealed that female gender, development of ARDS before ACTH test, and bacteremia were associated with greater RAI incidence. There was no difference in RAI incidence considering neurological diseases, age, type and source of infection and the main admission categories.. Female gender, bacteremia and early-onset ARDS were variables independently associated with greater RAI incidence in septic shock patients. There was no difference in the RAI incidence concerning other subgroups.

Topics: Adrenal Cortex; Adrenal Insufficiency; Adult; Aged; Bacteremia; Brazil; Community-Acquired Infections; Cosyntropin; Cross Infection; Elective Surgical Procedures; Emergencies; Female; Humans; Hydrocortisone; Inpatients; Intensive Care Units; Male; Middle Aged; Nervous System Diseases; Postoperative Complications; Prospective Studies; Respiratory Distress Syndrome; Shock, Septic

We wished to define the cortisol response to 250 micrograms intramuscular tetracosactrin (Synacthen) in acute hospital admissions, using a modern immunoassay for cortisol.. We performed a prospective study of, as near as possible, a consecutive series of 161 admissions to a single unit.. We studied 50 patients (age range 67-98, mean 80.3 years, 31-female, 19-male) admitted as an emergency, from whom it was possible to obtain informed consent, and whom it was possible to study within 24 hours of admission.. We measured baseline, increment and peak serum cortisol following administration of 250 micrograms intramuscular tetracosactrin between 0800 and 0900 hours.. Baseline cortisol concentrations ranged from 288 to 1585 nmol/l (mean 706; median 665). Peak cortisol concentrations ranged from 602 to 2265 nmol/l (mean 1076; median 999). Baseline and peak cortisol concentrations showed a significant correlation (P less than 0.001). Increment varied from 10 to 747 nmol/l (mean 374; median 336) and did not correlate with baseline.. In acute hospital admissions, baseline serum cortisol between 0800 and 0900 hours should exceed 250 nmol/l. Peak serum cortisol after 250 micrograms intramuscular tetracosactrin should exceed 600 nmol/l. Calculation of the increment is of no value.

Topics: Acute Disease; Adrenal Cortex; Aged; Aged, 80 and over; Cosyntropin; Dehydration; Emergencies; Female; Hospitalization; Humans; Hydrocortisone; Immunoassay; Male; Patient Admission; Prospective Studies