cosyntropin and Wounds-and-Injuries

To investigate the impact of etomidate on the rate of hospital-acquired pneumonia (HAP) in trauma patients and the effects of hydrocortisone in etomidate-treated patients.. This was a sub-study of the HYPOLYTE multi-centre, randomized, double-blind, placebo-controlled trial of hydrocortisone in trauma patients (NCT00563303). Inclusion criterion was trauma patient with mechanical ventilation (MV) of ≥48 h. The use of etomidate was prospectively collected. Endpoints were the results of the cosyntropin test and rate of HAP on day 28 of follow-up.. Of the 149 patients enrolled in the study, 95 (64 %) received etomidate within 36 h prior to inclusion. 79 (83 %) of 95 patients receiving etomidate and 34 of the 54 (63 %) not receiving etomidate had corticosteroid insufficiency (p = 0.006). The administration of etomidate did not alter basal cortisolemia (p = 0.73), but it did decrease the delta of cortisolemia at 60 min (p = 0.007). There was a correlation between time from etomidate injection to inclusion in the study and sensitivity to corticotropin (R (2) = 0.19; p = 0.001). Forty-nine (51.6 %) patients with etomidate and 16 (29.6 %) patients without etomidate developed HAP by day 28 (p = 0.009). Etomidate was associated with HAP on day 28 in the multivariate analysis (hazard ratio 2.48; 95 % confidence interval 1.19-5.18; p = 0.016). Duration of MV with or without etomidate was not significantly different (p = 0.278). Among etomidate-exposed patients, 18 (40 %) treated with hydrocortisone developed HAP compared with 31 (62 %) treated with placebo (p = 0.032). Etomidate-exposed patients treated with hydrocortisone had fewer ventilator days (p < 0.001).. Among the patients enrolled in the study, etomidate did not alter basal cortisolemia, but it did decrease reactivity to corticotropin. We suggest that in trauma patients, etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after etomidate use.

Topics: Adolescent; Adrenal Insufficiency; Adult; Aged; Anesthetics, Intravenous; Child; Child, Preschool; Cosyntropin; Cross Infection; Double-Blind Method; Etomidate; Female; Humans; Hydrocortisone; Male; Middle Aged; Pneumonia, Bacterial; Respiration, Artificial; Risk Factors; Wounds and Injuries; Young Adult

Acute adrenal insufficiency in the trauma patient is underrecognized and the impact poorly understood. Our hypothesis was that the identification and treatment of acute adrenal insufficiency reduces mortality in trauma patients. Institutional Review Board approval for the retrospective review of a prospective database from a Level 1 trauma center for 2002 to 2004 was obtained. The study population included patients receiving a cosyntropin stimulation test (250 microg) and/or random cortisol level based on our practice management guideline and an intensive care unit stay longer than 24 hours. Demographic, acuity, and outcome data were collected. The nonresponders had baseline cortisol levels less than 20 microg/dL or poststimulation rise less than 9 microg/dL. Independent t tests and chi2 statistics were used. One hundred thirty-seven patients had cosyntropin stimulation tests performed. Eighty-two (60%) patients were nonresponders of which 66 were treated with hydrocortisone and 16 went untreated as a result of the discretion of the attending physician. The 55 (40%) responders showed no statistical differences in outcome variables whether or not they received hydrocortisone. The untreated adrenal-insufficient patients had significantly higher mortality, longer hospital length of stay, intensive care unit days, and ventilator-free days. Conclusions were: (1) treatment of acute adrenal insufficiency reduces mortality by almost 50 per cent in the trauma patient; and (2) acute adrenal insufficiency recognized by low random cortisol levels or nonresponse to a stimulation tests should be considered for treatment.

Topics: Acute Disease; Adrenal Insufficiency; Adult; Cosyntropin; Drug Therapy, Combination; Glucocorticoids; Hormones; Humans; Hydrocortisone; Length of Stay; Middle Aged; Prevalence; Prospective Studies; Survival Rate; Trauma Centers; Trauma Severity Indices; Treatment Outcome; United States; Wounds and Injuries

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

Adrenocortical dysfunction is unusual in the unselected critically ill patient. Case reports document a state of corticosteroid responsive vasopressor dependence, resembling the systemic inflammatory response syndrome. The exact incidence of this disorder is unknown.. We prospectively studied the incidence of adrenal insufficiency during a 9-month period in a surgical intensive care unit (ICU) population. Trauma, general surgery, urology, and gynecologic-oncology patients were included. Patients who met criteria were given a cosyntropin stimulation test.. Overall, the incidence of adrenal insufficiency was 0.66%. In the subgroup of patients with greater than 14 days stay in the ICU, 6% were found to have adrenal insufficiency. In patients aged more than 55 years and with ICU stays of 14 days or greater, 11% were adrenally insufficient.. Screening of critically ill patients for adrenal insufficiency, particularly those with prolonged ICU stay and age greater than 55 years, is warranted.

Topics: Adrenocorticotropic Hormone; Adult; Aged; Aged, 80 and over; Aging; Cosyntropin; Hospital Mortality; Humans; Incidence; Intensive Care Units; Length of Stay; Middle Aged; Prospective Studies; Wounds and Injuries

Thirty-four patients who underwent abdominal or thoracic, or both, operation for injuries were studied. Serum and urinary cortisol levels were elevated perioperatively and returned to normal levels by the fourth postoperative day. Postoperative complication was associated with persistent elevation of levels of serum and urinary cortisol. Baseline serum cortisol levels correlated with Injury Severity Scores. Cosyntropin stimulation produced a significant rise in serum cortisol to a peak level of 47.4 +/- 10.2 (S.D.) micrograms per deciliter in patients after emergent operations for traumatic injury. Use of the cosyntropin stimulation test for the diagnosis of postoperative adrenal insufficiency can be extended to patients who undergo operation for traumatic injury.

Topics: Adrenal Glands; Adrenal Insufficiency; Circadian Rhythm; Cosyntropin; Humans; Hydrocortisone; Injury Severity Score; Postoperative Complications; Wounds and Injuries