cosyntropin and Multiple-Organ-Failure

To explore the relationship between cholesterol levels and the adrenal cortisol response to synacthen in critically ill patients.. Prospective observational study.. Critically ill patients with multiple organ dysfunction syndrome (MODS) with possible adrenal dysfunction defined as unexplained hypotension, ongoing inotropic support, unexplained fever, unexplained hyponatraemia or a combination of these symptoms.. HDL-cholesterol levels (HDL), total cholesterol levels (TC), and triglycerides (TG) before administration of synacthen. LDL-cholesterol was calculated using the Friedewald formula. Basal cortisol and response to 250 microg synacthen intravenously was measured. A cortisol rise of 0.25 micromol/l in a 30-min or 60-min blood sample after synacthen infusion was defined as a proper adrenal response.. Patients with a proper response to synacthen showed higher HDL-cholesterol levels than patients without that response ( P=0.02). Severity of disease as measured by APACHE II or SOFA was not a confounder. LDL-cholesterol levels were extremely low in both responders and non-responders and were not associated with the absolute rise in cortisol. In linear and logistic regression analysis HDL-cholesterol was the sole predictor of cortisol response.. Adrenal cortisol response to a "classic" 250-microg synacthen test relates in critically ill patients to HDL-cholesterol levels. LDL and TC levels did not show such a relation. These findings are in concordance with known biochemical pathways of cortisol production.

Topics: Adult; Aged; Aged, 80 and over; Cholesterol, HDL; Cosyntropin; Critical Care; Humans; Hydrocortisone; Logistic Models; Middle Aged; Multiple Organ Failure; Prospective Studies; Severity of Illness Index; Treatment Outcome

Topics: Chickenpox; Cosyntropin; Epilepsy; Fatal Outcome; Female; Hormones; Humans; Immunocompromised Host; Infant; Multiple Organ Failure; Tuberous Sclerosis

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