Corticosteroid insufficiency in acutely ill patients

Basal serum cortisol levels are not predictive of response to corticotropin but have prognostic significance in patients with septic shock

Because high levels of cortisol are frequently observed in patients with septic shock, low levels of serum cortisol are considered indicative of relative adrenal insufficiency (RAI). This study was performed to investigate whether pretest clinical characteristics, including basal serum cortisol levels, are predictive of serum cortisol response to corticotropin and whether basal cortisol levels have a prognostic significance in patients with septic shock. We performed a retrospective analysis of 68 patients with septic shock who underwent short corticotropin stimulation testing. RAI was defined as an increase in cortisol level <9 microgram/dL from baseline, and results showed that 48 patients (70.6%) had this insufficiency. According to the univariate analysis, the RAI group had significantly higher simplified acute physiology score II (SAPS II) and sequential organ failure assessment (SOFA) scores than the non-RAI group. The incidence of RAI was the same regardless of the basal serum cortisol level (p=0.447). The hospital mortality rate was 58.8% and was not significantly different between the RAI and non-RAI groups. However, a high basal serum cortisol level (> or =30 microgram/dL) was significantly associated with in-hospital mortality. In conclusion, our data suggest that basal serum cortisol levels are not predictive of serum cortisol response to corticotropin but have a significant prognostic value in patients with septic shock.

Functional adrenal insufficiency among critically ill patients with human immunodeficiency virus in a resource-limited setting

BACKGROUND

Functional adrenal insufficiency (FAI) is associated with increased mortality and is defined as subnormal cortisol production during acute severe illness.

METHODS

After screening 200 adult patients admitted in the medical emergency unit of Mulago Hospital, Kampala, Uganda, 113 critically ill HIV-infected adults not receiving corticosteroids were enrolled after obtaining informed consent to determine the prevalence and factors associated with FAI.

RESULTS

Functional adrenal insufficiency, defined in this study as morning total serum cortisol level of 3%) occurred in 52% (11 of 21) patients with FAI compared to 24% (22 of 92) patients with normal adrenal function (p= 0.01). Factors predicting FAI on multivariate analysis were use of rifampicin and eosinophilia. The mortality rate among patients with FAI (19%) was not significantly different when compared to that among patients with a normal cortisol response (33%) (p=0.221). Hyponatremia, hypoglycemia, hyperkalemia, postural hypotension and the use of ketoconazole were not associated with FAI in this study.

CONCLUSION

The diagnosis of FAI should be considered in severely ill patients with stage IV HIV disease using rifampicin or those found to have unexplained eosinophilia. Further studies to determine benefits of corticosteroids in critically ill HIV patients are needed in this setting.

Hemodynamic steroid responsiveness is predictive of neurological outcome after traumatic brain injury

INTRODUCTION

To determine the impact of physiologic doses of hydrocortisone on neurologic outcome after traumatic brain injury (TBI).

METHODS

We conducted a retrospective study in a neurocritical care unit at a university teaching hospital. We included 29 patients with moderate and severe TBI requiring vasoactive drugs to maintain adequate arterial blood pressure who received corticosteroid. Infected patients were excluded. Blood cortisol levels were measured before and 30 and 60 minutes after the administration of a high-dose corticotropin stimulation test (HDST). Patients received hydrocortisone replacement therapy (200-300 mg/day) and vasoactive drugs requirements were noted. Intracranial pressure was managed according to a predefined protocol.

RESULTS

A total of 14 out of 29 (48%) of patients were classified as responders to hydrocortisone (stopping vasoactive drugs within 3 days of starting hydrocortisone). The Glasgow Outcome Score (GOS) was used to assess neurologic outcome at 6 months. A favorable outcome (GOS 4 and 5) was observed in 11 out of 14 (79%) of responders and five out of 15 (33%) of nonresponders (p = 0.03). Of the responders, 12 out of 14 (85%) had a baseline cortisol below 414 nmol/L, and five out of 14 (36%) had primary adrenal insufficiency (AI) (primary AI: low baseline cortisol, and poor response to the HDST). Age, severity of injury, and response to hydrocortisone were predictive of outcome in multiple logistic regression analysis.

CONCLUSIONS

Adrenal insufficiency is frequent after TBI, and hydrocortisone replacement therapy seems to be associated with a favorable neurologic outcome.

[Steroids in the critical care children with septic shock and other conditions]

Steroids are indicated in paediatric intensive care as anti-inflammatory drugs or for substitutive treatment. During septic shock, the incidence of adrenal insufficiency (AI) varies between 18 à 52%, depending on the relative or absolute nature of the AI. Contrary to adults, for whom long courses of low doses of corticosteroids were shown to reduce mortality and increased shock reversibility, particularly in those with a negative synacthene test, no study provided sufficient evidence to show a benefit of steroids in terms of outcome in children with septic shock. In neonates, AI occurs frequently after cardiac surgery and the administration of steroids can improve haemodynamic condition. The recommended dose of hydrocortisone during septic shock or after cardiac surgery is 30 to 100 mg/m(2)/d. Dexamethasone is efficient to reduce postextubation stridor in children and neonate and the rate of reintubations in neonate. During croup, oral or parenteral steroids reduce clinical symptoms. Dexamethasone also reduces the incidence of severe chronic lung disease and the duration of tracheal intubation in premature infants. However the high incidence of side effects, particularly on the central nervous system, makes steroids currently not recommended for bronchopulmonary dysplasia. At last, steroids are indicated for severe asthma and for bacterial meningitis. In this latter indication, dexamethasone was shown to improve neurological outcome, indeed mortality in Haemophilus influenzae and Streptococcus pneumoniae meningitis.

Adrenal function in sepsis: the retrospective Corticus cohort study

OBJECTIVE

To refine the value of baseline and adrenocorticotropin hormone (ACTH)-stimulated cortisol levels in relation to mortality from severe sepsis or septic shock.

DESIGN

Retrospective multicenter cohort study.

SETTING

Twenty European intensive care units.

PATIENTS

Patients included 477 patients with severe sepsis and septic shock who had undergone an ACTH stimulation test on the day of the onset of severe sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Compared with survivors, nonsurvivors had higher baseline cortisol levels (29.5 +/- 33.5 vs. 24.3 +/- 16.5 microg/dL, p = .03) but similar peak cortisol values (37.6 +/- 40.2 vs. 35.2 +/- 22.9 microg/dL, p = .42). Thus, nonsurvivors had lower Deltamax (i.e., peak cortisol minus baseline cortisol) (6.4 +/- 22.6 vs. 10.9 +/- 12.9 microg/dL, p = .006). Patients with either baseline cortisol levels <15 microg/dL or a Deltamax <or=9 microg/dL had a likelihood ratio of dying of 1.26 (95% confidence interval, 1.11-1.44), a longer duration of shock, and a shorter survival time. Patients with a Deltamax <or=9 microg/dL but any baseline cortisol value had a likelihood ratio of dying of 1.38 (95% confidence interval, 1.18-1.61).

CONCLUSIONS

Although delta cortisol and not basal cortisol level was associated with clinical outcome, further studies are still needed to optimize the diagnosis of adrenal insufficiency in critical illness. Etomidate influenced ACTH test results and was associated with a worse outcome.

Glucocorticoid therapy for hypotension in the cardiac intensive care unit

In recent years, it has been our practice to treat persistent hypotension in the cardiac intensive care unit with glucocorticoids. We undertook a retrospective review in an attempt to identify predictors of a hemodynamic response to steroids and of survival in these patients. Patients who had received glucocorticoids for hypotension over a 2-year period were identified retrospectively. Summary measures of blood pressure, heart rate, urine output, inotrope score, and volume of infused fluid were calculated for the 12 hours before and the 24 hours following initiation of glucocorticoid therapy. A hemodynamic response was defined as a > or =20% increase in mean blood pressure without an increase in inotrope score following initiation of steroid therapy. Fifty-one patients were included, of whom 6 (11.8%) died. Serum cortisol was measured in 43 patients (84.3%) and was below the lower limit of normal (<5 microg/dl) in 20 of these (46.5%). Following initiation of steroid therapy, blood pressure and urine output increased, whereas heart rate, inotrope score, and infused volume decreased. There were 21 (41.1%) hemodynamic responders, all of whom survived, whereas 6 of 30 (20%) nonresponders died (p = 0.036). No predictors of a hemodynamic response to steroid were identified. Some critically ill children with cardiac disease and inotrope refractory hypotension demonstrated hemodynamic improvement following glucocorticoid administration. An improvement in blood pressure following administration of glucocorticoid was associated with survival, but we were unable to identify predictors of that response.

Relative adrenal insufficiency: an identifiable entity in nonseptic critically ill patients?

OBJECTIVE

To determine whether relative adrenal insufficiency (RAI) can be identified in nonseptic hypotensive patients in the intensive care unit (ICU).

DESIGN

Retrospective study in a medical-surgical ICU of a university hospital.

PATIENTS

One hundred and seventy-two nonseptic ICU patients (51% after trauma or surgery), who underwent a short 250 microg ACTH test because of > 6 h hypotension or vasopressor/inotropic therapy.

MEASUREMENTS

On the test day, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) score were calculated to estimate disease severity. The ICU mortality until day 28 was recorded. Best discriminative levels of baseline cortisol, increases and peaks were established using receiver operating characteristic curves. These and corticosteroid treatment (in n = 112, 65%), among other variables, were examined by multiple logistic regression and Cox proportional hazard regression analyses to find independent predictors of ICU mortality until day 28.

RESULTS

ICU mortality until day 28 was 23%. Nonsurvivors had higher SAPS II and SOFA scores. Baseline cortisol levels correlated directly with albumin levels and SAPS II. In the multivariate analyses, a cortisol baseline > 475 nmol/l and cortisol increase < 200 nmol/l predicted mortality, largely dependent on disease severity but independent of albumin levels. Corticosteroid (hydrocortisone) treatment was not associated with an improved outcome, regardless of the ACTH test results.

CONCLUSION

In nonseptic hypotensive ICU patients, a low cortisol/ACTH response and treatment with corticosteroids do not contribute to mortality prediction by severity of disease. The data thus argue against RAI identifiable by cortisol/ACTH testing and necessitating corticosteroid substitution treatment in these patients.

Bénéfices potentiels des traitements non anti-infectieux du choc septique: analyse critique de la littérature

Among numerous non anti-infective treatments proposed in the management of severe sepsis and septic shock, early administration of steroids and recombinant human activated protein C are the most studied and the major source of debate. Patients with functional adrenal insufficiency appear to be the best cases for early treatment with low doses of hydrocortisone. However, definition of adrenal dysfunction, interpretation of cortisol blood concentration and its appropriateness, investigation of the hypothamalo-pituitary-adrenal axis and value of corticotropin stimulation test are matter of discussion. Similarly, recombinant human activated protein C might be beneficial in patients with severe sepsis and septic shock but the results of clinical trials are controversial. Structure of the PROWESS pivotal study, post hoc analyses of numerous subgroups, use of severity scoring system for selection of the patients, unproven mechanisms of action of activated Protein C, interactions with combined treatments represent major sources of confusion and of debate in the analysis of the trials. Non anti-infective treatments should be considered in selected patients when appropriate conventional treatments have been implemented. Use of these new treatments should bring additional improvement in the prognosis in severely ill patients at high risk of death.

Perioperative management of the podiatric surgical patient

Advanced thought and planning are required when preparing for podiatric surgery. In addition to appropriate procedure selection and follow-up, perioperative management has a key role in patient and physician satisfaction. Neglect of this aspect of podiatric care can also be a source of malpractice. This article analyzes many of the common medical treatments currently employed and makes recommendations for treatment before, during, and after surgery.

Treatment of severe sepsis: where next? Current and future treatment approaches after the introduction of drotrecogin alfa

Severely septic patients continue to experience excessive morbidity and mortality despite recent advances in critical care. Although significant resources have been invested in new treatments, almost all have failed to improve outcomes. An improved understanding of sepsis pathophysiology, including the complex interactions between inflammatory, coagulation, and fibrinolytic systems, has accelerated the development of novel treatments. Recombinant human activated protein C (rhAPC), or drotrecogin alfa (activated) (DAA), is currently the only US Food and Drug Administration (FDA)-approved medicine for the treatment of severe sepsis, and only in patients with a high risk of death. This review will discuss the treatment of severe sepsis, focusing on recent discoveries and unresolved questions about DAA's optimal use. Increasing pharmacological experience has generated enthusiasm for investigating medicines already approved for other indications as treatments for severe sepsis. Replacement doses of hydrocortisone and vasopressin may reduce mortality and improve hypotension, respectively, in a subgroup of patients with catecholamine-refractory septic shock. In addition to discussing these new indications, this review will detail the provocative preliminary data from four promising treatments, including two novel modalities: antagonizing high mobility group box protein and inhibiting tissue factor (TF). Observational data from the uncontrolled administration of heparin or statins in septic patients will also be reviewed.

Coccidioides immitis fungemia: clinical features and survival in 33 adult patients

Coccidioides immitis is a fungus endemic to the southwestern United States. Susceptible hosts, including blacks, Hispanics, Filipinos, Native Americans, and those with compromised immunity, may develop disseminated disease, including fungemia. We retrospectively reviewed the records of all patients (n = 33) with Coccidioides immitis fungemia (CIF) at a 550-bed public hospital in Phoenix, Arizona, from 1990 to 2002. This is the largest reported series of CIF. The purpose of the study was to review the incidence, signs, symptoms, and outcomes of CIF. Twenty-nine patients had human immunodeficiency virus infection. CIF was associated with sepsis, end-stage alcoholic liver disease, and diabetes in four patients. Survival was poor; 24 of the 33 patients died within 28 days. CIF manifested as a systemic inflammatory response syndrome with progressive cardiorespiratory failure. Despite fluid loading, infusion of vasoactive agents, and mechanical ventilation with positive end-expiratory pressure, patients typically experienced a rapidly progressive course and death. CIF portends an ominous prognosis and typically occurs in the setting of advanced human immunodeficiency virus or medical or surgical crises.

Acute adrenal crisis after orthopedic surgery for pathologic fracture

Background

Adrenal crisis after surgical procedure is a rare but potentially catastrophic life-threatening event. Its manifestations, such as hypotension, tachycardia, hypoxia, and fever mimic the other more common postoperative complications. Clinical outcome is dependent upon early recognition of the condition and proper management with exogenous steroid administration.

Case presentation

We report a 75-year-old man who presented with shock immediately after surgery for a femoral fracture from lung cancer metastasis. Anemia and severe hyponatremia were detected. Despite adequate fluid resuscitation, nonspecific symptoms including hypotension, tachycardia, hypoxia, fever and confusion occurred. Emergent CT revealed enlarged bilateral adrenal glands. Under the diagnosis of adrenal crisis due to metastatic infiltration of adrenal glands, the patient was treated with appropriate steroid replacement resulting in rapid improvement and recovery.

Conclusion

We describe a case of adrenal crisis caused by the lack of adrenal reserve based on metastatic involvement and surgical stress, the first published case of adrenal crisis after surgery for a pathologic fracture from lung cancer metastasis. Surgeons treating pathologic fractures should be aware of this complication and familiar with its appropriate therapy because of increasing opportunity to care patients with metastatic bone tumors due to recent advances in cancer treatment.

Bilateral adrenal histoplasmosis in an immunocompetent man

Histoplasmosis is a fungal disease that is endemic in Brazil. It may present as chronic pulmonary infection or in disseminated form. Disseminated histoplasmosis frequently affects the adrenal gland; however, unilateral involvement in immunosuppressed patients is the usual presentation. We report a case of an elderly immunocompetent male with history of weight loss, fever and bilateral adrenal mass who was successfully treated with itraconazole.

The Use of Prognostic Indicators in the Development of a Statistical Model Predictive for Adrenal Insufficiency in Trauma Patients

We performed a retrospective chart review of trauma patients admitted to Palmetto Richland Memorial Hospital and identified 63 cases of adrenal insufficiency along with 65 trauma patient controls. Two statistical models, a neural network and a multiple logistic regression, were developed to predict patients with increased risk of developing adrenal insufficiency. Each model had 11 selected independent variables, along with patient demographic data, to make a probabilistic prediction of patient outcome. The neural network model was trained with 102 patients to identify linear and nonlinear relationships that could yield a predictive capability. The neural network achieved an accuracy of 71 per cent. The logistic regression model achieved an accuracy of 82 per cent. With these models, we have shown the feasibility of a method to more accurately screen patients with an increased risk of adrenal insufficiency. This ability should allow earlier identification and treatment of patients with adrenal insufficiency. Further development with a larger database is needed to improve the accuracy of the present models.

Management of sepsis

Severe sepsis remains a common cause of death in surgical patients. Eradication of the septic source and supportive care has long been the mainstay of treatment. In recent years, however, early goal-directed therapy, tighter glucose control, administration of drotrecogin alfa (activated), and steroid replacement have produced improved morbidity and mortality. In the future, a better understanding of the pathophysiology of sepsis and clinical studies may further improve outcomes from severe sepsis.

Bilateral adrenal hemorrhage: An overlooked cause of hypotension

Bilateral adrenal hemorrhage resulting in acute adrenal insufficiency is a rare complication of anticoagulant therapy. We present the case of a patient who came to the Emergency Department with unsuspected adrenal insufficiency, followed by a second visit within 1 month with shock, to demonstrate the importance of early detection and treatment.

A modified goal-directed protocol improves clinical outcomes in intensive care unit patients with septic shock: a randomized controlled trial

We evaluated whether a goal-directed protocol, without measurement of central venous oxygen saturation, would improve survival in medical intensive care unit (ICU) patients with septic shock. This is a prospective, controlled study in a 24-bed medical ICU at a tertiary care hospital. From a total of 241 consecutive patients with septic shock, 224 were randomly assigned to receive therapy with or without a written protocol using central venous pressure, mean arterial pressure, and urine output as therapeutic goals. Baseline characteristics were similar between groups. Implementation of goal-directed therapy caused a more rapid reversal of persistent shock (47 +/- 22.8 vs. 65.4 +/- 32.1 h, P = 0.006) and decreases of ICU (50% vs. 67.2%, P = 0.009) and in-hospital (53.7% vs. 71.6%, P = 0.006) mortality rates compared with non-goal-directed therapy. Patients receiving goal-directed therapy also had less risk for developing central nervous system or renal failure than patients without. Patients with goal-directed therapy received more fluid during the period of persistent shock (136.2 +/- 119 vs. 88.6 +/- 57.7 mL h, P = 0.034) and less delay in vasopressor administration (78 +/- 22.2 vs. 104.4 +/- 29 min, P = 0.001) than patients with non-goal therapy. Implementation of a goal-directed protocol improves survival and clinical outcomes in ICU patients with septic shock. These benefits may arise from adequate fluid resuscitation, earlier vasopressor administration, rapid shock reversal, and protection of major organ function. With central venous oxygen saturation measurement to detect tissue perfusion, the clinical outcomes may be further improved.

Relative adrenal insufficiency in etomidate-naïve patients with septic shock

A recent study reported that 77% of patients with septic shock had relative adrenal insufficiency. However, all patients were mechanically ventilated and received high-dose inotropes. In addition, at least 24% had prior exposure to etomidate, a drug known to suppress adrenal function. We studied the incidence of relative adrenal insufficiency in etomidate-naïve patients with septic shock by analysing the adrenal response to high-dose short synacthen test in 113 consecutive patients from three university-affiliated intensive care units in Australia. Patients were allocated to three groups according to severity of illness and inclusion criteria of the trial of low dose hydrocortisone supplementation using information from patient records. Of the 113 patients, 98 had septic shock (Group A). The incidence of relative adrenal insufficiency in this subpopulation was 24.5%. Eighty-one per cent of patients with septic shock were mechanically ventilated (Group B). In this group, the incidence of relative adrenal insufficiency was 27.8%. Only 38 of the 98 patients with septic shock (39%) fulfilled inclusion criteria for the steroid supplementation trial (Group C). In this group, the incidence of relative adrenal insufficiency was only 34.2%. In all groups its presence was associated with a higher mortality. We conclude that the incidence of relative adrenal insufficiency in etomidate-naive septic shock patients was lower than observed in the steroid supplementation trial. Further, in those who fulfilled inclusion criteria for the trial, the incidence of relative adrenal insufficiency was half that reported by the trial. Our observations raise concerns about the generalizability of the findings of the above trial to etomidate-naïve patients.

Adrenal function testing in patients with septic shock

INTRODUCTION

Adrenal failure (AF) is associated with increased mortality in septic patients. Nonetheless, there is no agreement regarding the best diagnostic criteria for AF. We compared the diagnosis of AF considering different baseline total cortisol cutoff values and Deltamax values after low (1 microg) and high (249 microg) doses of corticotropin, we analyzed the impact of serum albumin on AF identification and we correlated laboratorial AF with norepinephrine removal.

METHODS

A prospective noninterventional study was performed in an intensive care unit from May 2002 to May 2005, including septic shock patients over 18 years old without previous steroid usage. After measurement of serum albumin and baseline total cortisol, the patients were sequentially submitted to 1 microg and 249 microg corticotropin tests with a 60-minute interval between doses. Post-stimuli cortisol levels were drawn 60 minutes after each test (cortisol 60 and cortisol 120). The cortisol 60 and cortisol 120 values minus baseline were called Deltamax1 and Deltamax249, respectively. Adrenal failure was defined as Deltamax249 < or = 9 microg/dl or baseline cortisol < or = 10 microg/dl. Other baseline cortisol cutoff values referred to as AF in other studies (< or =15, < or =20, < or =25 and < or =34 mug/dl) were compared with Deltamax249 < or = 9 microg/dl and serum albumin influence. Norepinephrine removal was compared with the baseline cortisol values and Deltamax249 values.

RESULTS

We enrolled 102 patients (43 male). AF was diagnosed in 22.5% (23/102). Patients with albumin < or =2.5 g/dl presented a lower baseline total cortisol level (15.5 microg/dl vs 22.4 microg/dl, P = 0.04) and a higher frequency of baseline cortisol < or =25 microg/dl (84% vs 58.3%, P = 0.05) than those with albumin > 2.5 g/dl. The Deltamax249 levels and Deltamax249 < or = 9, however, were not affected by serum albumin (14.5 microg/dl vs 18.8 microg/dl, P = 0.48 and 24% vs 25%, P = 1.0). Baseline cortisol < or = 23.6 microg/dl was the most accurate diagnostic threshold to determine norepinephrine removal according to the receiver operating characteristic curve.

CONCLUSION

AF was identified in 22.5% of the studied population. Since Deltamax249 < or = 9 microg/dl results were not affected by serum albumin and since the baseline serum total cortisol varied directly with albumin levels, we propose that Deltamax249 < or = 9 microg/dl, which means Deltamax after high corticotropin dose may be a better option for AF diagnosis whenever measurement of free cortisol is not available. Baseline cortisol < or =23.6 microg/dl was the best value for predicting norepinephrine removal in patients without corticosteroid treatment.

Selenium in Intensive Care (SIC): Results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock*

OBJECTIVE

Sepsis is associated with an increase in reactive oxygen species and low endogenous antioxidative capacity. We postulated that high-dose supplementation of sodium-selenite would improve the outcome of patients with severe sepsis and septic shock.

DESIGN

Prospective randomized, placebo-controlled, multiple-center trial.

SETTING

Eleven intensive care units in Germany.

PATIENTS

Patients were 249 patients with severe systemic inflammatory response syndrome, sepsis, and septic shock and an Acute Physiology and Chronic Health Evaluation (APACHE) III score >70.

INTERVENTIONS

Patients received 1000 microg of sodium-selenite as a 30-min bolus injection, followed by 14 daily continuous infusions of 1000 microg intravenously, or placebo.

MEASUREMENTS AND MAIN RESULTS

The primary end point was 28-day mortality; secondary end points were survival time and clinical course of APACHE III and logistic organ dysfunction system scores. In addition, selenium levels in serum, whole blood, and urine as well as serum glutathione-peroxidase-3 activity were measured. From 249 patients included, 11 patients had to be excluded. The intention-to-treat analysis of the remaining 238 patients revealed a mortality rate of 50.0% in the placebo group and 39.7% in the selenium-treated group (p = .109; odds ratio, 0.66; confidence interval, 0.39-1.1). A further 49 patients had to be excluded before the final analysis because of severe violations of the study protocol. In the remaining 92 patients of the study group, the 28-day mortality rate was significantly reduced to 42.4% compared with 56.7% in 97 patients of the placebo group (p = .049, odds ratio, 0.56; confidence interval, 0.32-1.00). In predefined subgroup analyses, the mortality rate was significantly reduced in patients with septic shock with disseminated intravascular coagulation (n = 82, p = .018) as well as in the most critically ill patients with an APACHE III score > or =102 (>75% quartile, n = 54, p = .040) or in patients with more than three organ dysfunctions (n = 83, p = .039). Whole blood selenium concentrations and glutathione peroxidase-3 activity were within the upper normal range during selenium treatment, whereas they remained significantly low in the placebo group. There were no side effects observed due to high-dose sodium-selenite treatment.

CONCLUSIONS

The adjuvant treatment of patients with high-dose sodium-selenite reduces mortality rate in patients with severe sepsis or septic shock.

Post-traumatic stress disorder in somatic disease: lessons from critically ill patients

Post-traumatic stress disorder (PTSD) is a well-recognized complication of severe illness. PTSD has been described in patients after multiple trauma, burns, or myocardial infarction with a particularly high incidence in survivors of acute pulmonary failure (Acute Respiratory Distress Syndrome) or septic shock. Many patients with evidence of PTSD after critical illness have been treated in intensive care units (ICUs). Studies in long-term survivors of ICU treatment demonstrated a clear and vivid recall of different categories of traumatic memory such as nightmares, anxiety, respiratory distress, or pain with little or no recall of factual events. A high number of these traumatic memories from the ICU has been shown to be a significant risk factor for the later development of PTSD in long-term survivors. In addition, patients in the ICU are often treated with stress hormones like epinephrine, norepinephrine, or cortisol. The number of the above-mentioned categories of traumatic memory increased with the totally administered dosages of catecholamines and cortisol, and the evaluation of these categories at different time points after discharge from the ICU showed better memory consolidation with higher dosages of stress hormones administered. Conversely, the prolonged administration of beta-adrenergic antagonists during the recovery phase after cardiac surgery resulted in a lower number of traumatic memories and a lower incidence of stress symptoms at 6 months after surgery. Findings with regard to the administration of the stress hormone cortisol were more complex, however. Several studies from our group have demonstrated that the administration of stress doses of cortisol to critically ill patients resulted in a significant reduction of PTSD symptoms measured after recovery without influencing the number of categories of traumatic memory. This can possibly be explained by a cortisol-induced temporary impairment in traumatic memory retrieval that has previously been demonstrated in both rats and humans. ICU therapy of critically ill patients can serve as a stress model that allows the delineation of stress hormone effects on traumatic memory and PTSD development. This could also result in new approaches for prophylaxis and treatment of stress-related disorders.

Surgical Trauma-Induced Adrenal Insufficiency is Associated with Postoperative Inflammatory Responses

The hypothalamic-pituitary-adrenal axis is an essential component for the maintenance of homeostasis following trauma. Major surgical trauma often induces overwhelming inflammatory responses leading to sepsis and organ dysfunction. This study was designed to evaluate the adrenal responses both before and after various degrees of surgical trauma and to determine the incidence of postoperative relative adrenal insufficiency resulting in the marked inflammatory response often associated with postoperative complications. Fifty-one surgical patients were divided into groups who underwent major, moderate, and minor surgeries. Before the operation and during resting conditions, a short corticotropin (ACTH) stimulation test was performed in each patient. The postoperative concentrations of serum cortisol, interleukin (IL)-6, IL-10, C-reactive protein (CRP), and plasma ACTH were measured. Fifty of 51 patients were identified as responders to ACTH. The postoperative cortisol levels were the same as those obtained by ACTH stimulation in highly and moderately stressful surgeries. The increases in postoperative IL-6 and CRP levels were greatest with major surgery, intermediate with moderate surgery, and least with minor surgery. Furthermore, plasma ACTH levels increased after major and moderate surgeries; however, there was no significant differences in postoperative serum IL-10 levels. Systemic inflammatory response syndrome (SIRS) was found in 11 of 17 patients (64.7%) who underwent major surgery and in 4 of 16 patients (25%) who underwent moderate surgery (p=0.037). The duration of SIRS was significantly longer in patients undergoing major surgery (62+/-20 hrs) than in patients undergoing moderate surgery (21+/-3 hrs, p=0.038). Postoperative complications were more frequent in patients undergoing major surgery (41.2%) than in patients undergoing moderate surgery (6.3%, p=0.039). Furthermore, there were significant differences in the length of the postoperative stay among the three groups (p<0.01). One nonresponder had serious postoperative inflammatory complications. These results suggest that a short ACTH stimulation test performed preoperatively is a helpful method for determining the maximal cortisol response to surgical trauma and to identify high-risk individuals and that a relative postoperative adrenal insufficiency may be closely related to the decreased cortisol secretion following major surgical trauma.

Pituitary-adrenal responses to human corticotropin-releasing hormone in critically ill patients

OBJECTIVE

To investigate the pattern of pituitary-adrenal responses to human corticotropin-releasing hormone (hCRH) in critically ill patients and to examine the relation between responses and clinical outcome.

DESIGN AND SETTING

Prospective study in consecutive critically ill patients in a general intensive care unit in a teaching hospital.

PATIENTS

The study included 37 critically ill, mechanically ventilated patients with diverse underlying diagnoses (28 men, 9 women; median age 56 years).

INTERVENTIONS

A morning blood sample was obtained to measure baseline cortisol, corticotropin (ACTH), and cytokines. Patients were then injected with 100 microg hCRH, and plasma cortisol and ACTH were measured over a period of 2 h.

MEASUREMENTS AND RESULTS

In the overall patient population baseline and peak cortisol concentrations following hCRH were 16+/-5 and 21+/-5 microg/dl, respectively, and median baseline and peak ACTH levels 23 and 65 pg/ml, respectively. Higher ACTH levels and longer release of cortisol were noted in nonsurvivors (n=18) than in survivors (n=19). Furthermore, nonsurvivors had higher concentrations of interleukin 8 (115 vs. 38 pg/ml) and interleukin 6 (200 vs. 128 pg/ml) than survivors.

CONCLUSIONS

Critically ill patients demonstrate altered pituitary-adrenal axis responses to hCRH. This is particularly evident in the sickest patients with the highest degree of inflammatory profile who ultimately do not survive.

Diagnosis of Adrenal Insufficiency in Severe Sepsis and Septic Shock

RATIONALE

Diagnosis of adrenal insufficiency in critically ill patients has relied on random or cosyntropin-stimulated cortisol levels, and has not been corroborated by a more accurate diagnostic standard.

OBJECTIVE

We used the overnight metyrapone stimulation test to investigate the diagnostic value of the standard cosyntropin stimulation test, and the prevalence of sepsis-associated adrenal insufficiency.

METHODS

This was an inception cohort study.

MEASUREMENTS AND RESULTS

In two consecutive septic cohorts (n = 61 and n = 40), in 44 patients without sepsis and in 32 healthy volunteers, we measured (1) serum cortisol before and after cosyntropin stimulation, albumin, and corticosteroid-binding globulin levels, and (2) serum corticotropin, cortisol, and 11beta-deoxycortisol levels before and after an overnight metyrapone stimulation. Adrenal insufficiency was defined by postmetyrapone serum 11beta-deoxycortisol levels below 7 microg/dl. More patients with sepsis (31/61 [59% of original cohort with sepsis] and 24/40 [60% of validation cohort with sepsis]) met criteria for adrenal insufficiency than patients without sepsis (3/44; 7%) (p < 0.001 for both comparisons). Baseline cortisol (< 10 microg/dl), Delta cortisol (< 9 microg/dl), and free cortisol (< 2 microg/dl) had a positive likelihood ratio equal to infinity, 8.46 (95% confidence interval, 1.19-60.25), and 9.50 (95% confidence interval, 1.05-9.54), respectively. The best predictor of adrenal insufficiency (as defined by metyrapone testing) was baseline cortisol of 10 microg/dl or less or Delta cortisol of less than 9 microg/dl. The best predictors of normal adrenal response were cosyntropin-stimulated cortisol of 44 microg/dl or greater and Delta cortisol of 16.8 microg/dl or greater.

CONCLUSIONS

In sepsis, adrenal insufficiency is likely when baseline cortisol levels are less than 10 microg/dl or delta cortisol is less than 9 microg/dl, and unlikely when cosyntropin-stimulated cortisol level is 44 microg/dl or greater or Delta cortisol is 16.8 microg/dl or greater.

Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress

CONTEXT

We recently demonstrated that 28-d bed rest in healthy volunteers results in a moderate loss of lean leg mass and strength.

OBJECTIVE

The objective of this study was to quantify changes in muscle protein kinetics, body composition, and strength during a clinical bed rest model reflecting both physical inactivity and the hormonal stress response to injury or illness.

DESIGN

Muscle protein kinetics were calculated during a primed, continuous infusion (0.08 micromol/kg.min) of 13C6-phenylalanine on d 1 and 28 of bed rest.

SETTING

The setting for this study was the General Clinical Research Center at the University of Texas Medical Branch.

PARTICIPANTS

Participants were healthy male volunteers (n = 6, 28 +/- 2 yr, 84 +/- 4 kg, 178 +/- 3 cm).

INTERVENTION

During bed rest, hydrocortisone sodium succinate was administered iv (d 1 and 28) and orally (d 2-27) to reproduce plasma cortisol concentrations consistent with trauma or illness (approximately 22 microg/dl).

MAIN OUTCOME MEASURES

We hypothesized that inactivity and hypercortisolemia would reduce lean muscle mass, leg extension strength, and muscle protein synthesis.

RESULTS

Volunteers experienced a 28.4 +/- 4.4% loss of leg extension strength (P = 0.012) and a 3-fold greater loss of lean leg mass (1.4 +/- 0.1 kg) (P = 0.004) compared with our previous bed rest-only model. Net protein catabolism was primarily due to a reduction in muscle protein synthesis [fractional synthesis rate, 0.081 +/- 0.004 (d 1) vs. 0.054 +/- 0.007%/h (d 28); P = 0.023]. There was no change in muscle protein breakdown.

CONCLUSION

Prolonged inactivity and hypercortisolemia represents a persistent catabolic stimulus that exacerbates strength and lean muscle loss via a chronic reduction in muscle protein synthesis.

The hypothalamic-pituitary-adrenal axis in critical illness

The hypothalamic-pituitary-adrenal response to stress is a dynamic process. The homeostatic corrections that have emerged in the course of human evolution to cope with the catastrophic events during critical illness involve a complex multisystem endeavor. Although the repertoire of endocrine changes has been probed in some detail, discerning the vulnerabilities and failures of this system is far more challenging. One of the most controversially debated topics in the current literature is the characterization and optimal treatment of allegedly inadequate adaptations of the hypothalamic-pituitary-adrenal axis during critical illness. This outline attempts to touch briefly some of the debated issues, stir the discussion, and thereby contribute to resolving the dispute.

Relative adrenal insufficiency manifested with multiple organ dysfunction in a liver transplant patient

Relative adrenal insufficiency is now a well-known clinical condition that occurs in critically ill patients particularly with septic complication. However, this pathology has long been unrecognized until recently in liver transplantation patients, for whom postoperative immunosuppressive therapies almost always comprise corticosteroids. We report an obvious case of relative adrenal insufficiency manifested by severe multiple organ dysfunction in a recipient after living donor liver transplantation (LDLT). A 38-year-old woman with multiple hepatocellular carcinoma developed refractory liver failure 2 months after the completion of the dual treatment; namely a cytoreductive right hepatectomy for bulky main tumors followed by 2 courses of percutaneous isolated hepatic perfusion for residual tumors in the remnant liver. She underwent a right-lobe LDLT, and postoperative immunosuppression was initiated with a low-dose tacrolimus monotherapy without corticosteroid because of a severe septic condition before transplantation. Postoperatively, she developed progressive hyperbilirubinemia, renal dysfunction, and coagulopathy. As the corticotropin stimulation test suggested the relative adrenal insufficiency, corticosteroid was commenced 40 days after LDLT. Thereafter, multiple organ dysfunction resolved dramatically and promptly. The patient is presently alive and well with completely normalized liver function 45 months after LDLT.

Acute adrenal insufficiency

Adrenal insufficiency is a rare disorder, usually with gradually evolving clinical symptoms and signs. Occasionally, an acute adrenal insufficiency crisis can become a life-threatening condition because of acute interruption of a normal or hyperfunctioning adrenal or pituitary gland or sudden interruption of a adrenal replacement therapy. Acute stress situations can aggravate the symptomatology. A simple strategy or diagnostic screening and early intervention with sodium chloride-containing fluids and hydrocortisone should be widely implemented for cases with suspicion of an acute Addison disease crisis. In contrast, the chronic replacement dosage for patients with adrenal insufficiency should be as low as possible with clear instructions for dosage adjustments in case of stress or acute emergencies.

The dynamic neuroendocrine response to critical illness

The severity of striking alterations in the hypothalamic-anterior pituitary-peripheral hormone axes, which are the hallmark of severity of critical illness, is associated with a high risk for morbidity and mortality. Most attempts to correct the hormone balance are ineffective or harmful because of lack of pathophysiologic understanding. Extensive research has provided more insight in the biphasic neuroendocrine response to critical illness: the acute phase is characterized by an actively secreting pituitary but low peripheral effector hormone levels. In contrast, in prolonged critical illness, uniform suppression of the neuroendocrine axes, predominantly of hypothalamic origin, contributes to low serum levels of the respective target-organ hormones.

Pro-con debate: steroid use in ACTH non-responsive septic shock patients with high baseline cortisol levels

Steroid use in critically ill, vasopressor-dependant, septic patients has gained increased acceptance in recent years with the publication of encouraging data. However, with renewed interest and/or attention comes increased debate and analysis. As a result, it is not surprising to find that there is still significant controversy with regards to the role of steroids in many patients. In this article, two expert groups debate the role of steroid use in a septic shock patient with arguably no clear evidence of adrenal insufficiency.

Emerging drugs for the treatment of sepsis

Septic shock still places a major burden on the healthcare system, although recent years have been marked by the demonstration that corticosteroids and activated protein C may substantially improve survival in selected populations. This review discusses the current management of septic shock and the potential development of new therapeutics following impressive advances in the pathomechanisms of septic shock.

Management of sepsis during the early "golden hours"

Severe sepsis and septic shock are common causes of morbidity and mortality. Interventions directed at specific endpoints, when initiated early in the "golden hours" of patient arrival at the hospital, seem to be promising. Early hemodynamic optimization, administration of appropriate antimicrobial therapy, and effective source control of infection are the cornerstones of successful management. In patients with vasopressor-dependent septic shock, provision of physiologic doses of replacement steroids may result in improved survival. Administration of drotrecogin alfa (activated), (activated protein C) has been shown to improve survival in patients with severe sepsis and septic shock who have a high risk of mortality. In this article we review the multi-modality approach to early diagnosis and intervention in the therapy of patients with severe sepsis and septic shock.

The Role of Toll-like Receptors in the Immune-Adrenal Crosstalk

Sepsis and septic shock remain major health concerns worldwide, and rapid activation of adrenal steroid release is a key event in the organism's first line of defense during this form of severe illness. Toll-like receptors (TLRs) are critical in the early immune response upon bacterial infection, and recent data from our lab demonstrate a novel link between the innate immune system and the adrenal stress response mediated by TLRs. Glucocorticoids and TLRs regulate each other in a bidirectional way. Bacterial toxins acting through TLRs directly activate adrenocortical steroid release. TLR-2 and TLR-4 are expressed in human and mice adrenals and TLR-2 deficiency is associated with an impaired glucocorticoid response. Furthermore, TLR-2 deficiency in mice is associated with marked cellular alterations in adrenocortical tissue. TLR-2-deficient mice have an impaired adrenal corticosterone release following inflammatory stress induced by bacterial cell wall compounds. This defect appears to be associated with a decrease in systemic and intraadrenal cytokine expression. In conclusion, TLRs play a crucial role in the immune-adrenal crosstalk. This close functional relationship needs to be considered in the treatment of inflammatory diseases requiring an intact adrenal stress response.

Adrenal insufficiency in patients with cirrhosis and septic shock: Effect of treatment with hydrocortisone on survival

Relative adrenal insufficiency is frequent in patients with severe sepsis and is associated with hemodynamic instability, renal failure, and increased mortality. This study prospectively evaluated the effects of steroids on shock resolution and hospital survival in a series of 25 consecutive patients with cirrhosis and septic shock (group 1). Adrenal function was evaluated by the short corticotropin test within the first 24 hours of admission. Patients with adrenal insufficiency were treated with stress doses of intravenous hydrocortisone (50 mg/6 h). Data were compared to those obtained from the last 50 consecutive patients with cirrhosis and septic shock admitted to the same intensive care unit in whom adrenal function was not investigated and who did not receive treatment with steroids (group 2). Incidence of adrenal insufficiency in group 1 was 68% (17 patients). Adrenal dysfunction was frequent in patients with advanced cirrhosis (Child C: 76% vs. Child B: 25%, P = .08). Resolution of septic shock (96% vs. 58%, P = .001), survival in the intensive care unit (68% vs. 38%, P = .03), and hospital survival (64% vs. 32%, P = .003) were significantly higher in group 1. The main causes of death in group 1 were hepatorenal syndrome or liver failure (7 of 9 patients). In contrast, refractory shock caused most of the deaths in group 2 (20 of 34 patients). In conclusion, relative adrenal insufficiency is very frequent in patients with advanced cirrhosis and septic shock. Hydrocortisone administration in these patients is associated with a high frequency of shock resolution and high survival rate.

Endocrine aspects of acute and prolonged critical illness

Critical illness is characterized by striking alterations in the hypothalamic-anterior-pituitary-peripheral-hormone axes, the severity of which is associated with a high risk of morbidity and mortality. Most attempts to correct hormone balance have been shown ineffective or even harmful because of a lack of pathophysiologic insight. There is a biphasic (neuro)endocrine response to critical illness. The acute phase is characterized by an actively secreting pituitary, but the concentrations of most peripheral effector hormones are low, partly due to the development of target-organ resistance. In contrast, in prolonged critical illness, uniform (predominantly hypothalamic) suppression of the (neuro)endocrine axes contributes to the low serum levels of the respective target-organ hormones. The adaptations in the acute phase are considered to be beneficial for short-term survival. In the chronic phase, however, the observed (neuro)endocrine alterations appear to contribute to the general wasting syndrome. With the exception of intensive insulin therapy, and perhaps hydrocortisone administration for a subgroup of patients, no hormonal intervention has proven to beneficially affect outcome. The combined administration of hypothalamic releasing factors does, however, hold promise as a safe therapy to reverse the (neuro)endocrine and metabolic abnormalities of prolonged critical illness by concomitant reactivation of the different anterior-pituitary axes.

Is there an optimal corticosteroid regimen for the management of an acute exacerbation of chronic obstructive pulmonary disease?

Systemic corticosteroids are standard of care for the management of an acute exacerbation of chronic obstructive pulmonary disease (COPD). Several prospective, randomized trials demonstrated modest improvements in patient outcomes when short courses of systemic corticosteroids were used. However, the most appropriate dosage regimen remains controversial, as the corticosteroid regimens used in these trials differed greatly, and no studies have directly compared medium-, high-, and low-dose regimens. In addition, data are lacking on the safety, efficacy, and appropriate dosing of systemic corticosteroids in women and in patients with an acute exacerbation of COPD and concomitant pneumonia or severe respiratory failure. Systemic corticosteroid use is associated with several adverse effects that are dose and/or duration dependent. Evidence suggests that higher dose corticosteroid regimens may place patients at increased short-term and long-term risk, without additional clinical benefit. Tapering of systemic corticosteroid regimens, although a common practice, is unnecessary in most circumstances. The risk for hypothalamic-pituitary-adrenal-axis suppression is negligible when low-dose, short-course corticosteroid regimens are used, and no evidence exists to suggest that abruptly stopping a low-dose steroid regimen will increase the risk of disease relapse. Still, no studies have directly compared tapered and non-tapered regimens in patients with an acute exacerbation of COPD. Consistent with clinical guideline recommendations, safety and efficacy data support the use of low-dose corticosteroid regimens such as prednisone 40 mg orally once/day for 10-14 days in most patients with an acute exacerbation of COPD. Further studies are needed to clarify the optimal systemic corticosteroid regimen for an acute exacerbation of COPD.

Relative adrenal insufficiency after cardiac arrest: impact on postresuscitation disease outcome

The purpose of this study is to prospectively evaluate the cortisol response and determine the relative adrenal insufficiency after return of spontaneous circulation (ROSC).

METHODS

This is a prospective cohort study describing the prevalence of relative adrenal insufficiency in consecutive patients admitted to an intensive care unit following ROSC (>24 hours) after cardiac arrest. The study institution is a 1,300-bed urban hospital with an annual intensive care unit census of 80. Descriptive statistics is used to report results.

RESULTS

This study included 30 patients over a 1-year period. The mean patient age was 52 years, and there were 15 (50%) males. The most common etiology for cardiac arrest was unknown, and the most common initial rhythm was asystole. There were 16 (53%) witnessed arrests. The mean time from arrest to cardiopulmonary resuscitation was 8 minutes, and the mean time from arrest to ROSC was 23 minutes. Relative adrenal insufficiency (incremental response to corticotrophin test < 9 microg/dL) at initial 12 to 24 hours and >24 to 48 hours occurred in 13 (43%) and 10 (33%) patients, respectively. All basal cortisol values were normal to high. Nineteen (58%) patients survived. The mean cortisol values at the initial 12 to 24 hours and >24 to 48 hours were similar among survivors and nonsurvivors. Relative adrenal insufficiency was present in only 5 (26%) survivors.

CONCLUSION

Relative adrenal insufficiency may be associated with the increased mortality rate in patients with return of circulation after cardiac arrest. Although basal cortisol values were normal to high, treatment of relative adrenal insufficiency with corticosteroids may decrease the mortality rate. Additional studies are needed to confirm this association and to determine the effectiveness of treating relative adrenal insufficiency.

Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods

CONTEXT

Activation of the hypothalamic-pituitary-adrenal (HPA) axis represents one of several important responses to stressful events and critical illnesses. Despite a large volume of published data, several controversies continue to be debated, such as the definition of normal adrenal response, the concept of relative adrenal insufficiency, and the use of glucocorticoids in the setting of critical illness.

OBJECTIVES

The primary objective was to review some of the modulating factors and limitations of currently used methods of assessing HPA function during critical illness and provide alternative approaches in that setting.

DESIGN

This was a critical review of relevant data from the literature with inclusion of previously published as well as unpublished observations by the author. Data on HPA function during three different forms of critical illnesses were reviewed: experimental endotoxemia in healthy volunteers, the response to major surgical procedures in patients with normal HPA, and the spontaneous acute to subacute critical illnesses observed in patients treated in intensive care units.

SETTING

The study was conducted at an academic medical center.

PATIENTS/PARTICIPANTS

Participants were critically ill subjects.

INTERVENTION

There was no intervention.

MAIN OUTCOME MEASURE

The main measure was to provide data on the superiority of measuring serum free cortisol during critical illness as contrasted to those of total cortisol measurements.

RESULTS

Serum free cortisol measurement is the most reliable method to assess adrenal function in critically ill, hypoproteinemic patients. A random serum free cortisol is expected to be 1.8 microg/dl or more in most critically ill patients, irrespective of their serum binding proteins. Because the free cortisol assay is not currently available for routine clinical use, alternative approaches to estimate serum free cortisol can be used. These include calculated free cortisol (Coolens' method) and determining the free cortisol index (ratio of serum cortisol to transcortin concentrations). Preliminary data suggest that salivary cortisol measurements might be another alternative approach to estimating the free cortisol in the circulation. When serum binding proteins (albumin, transcortin) are near normal, measurements of total serum cortisol continue to provide reliable assessment of adrenal function in critically ill patients, in whom a random serum total cortisol would be expected to be 15 microg/dl or more in most patients. In hypoproteinemic critically ill subjects, a random serum total cortisol level is expected to be 9.5 microg/dl or more in most patients. Data on Cosyntropin-stimulated serum total and free cortisol levels should be interpreted with the understanding that the responses in critically ill subjects are higher than those of healthy ambulatory volunteers. The Cosyntropin-induced increment in serum total cortisol should not be used as a criterion for defining adrenal function, especially in critically ill patients.

CONCLUSIONS

The routine use of glucocorticoids during critical illness is not justified except in patients in whom adrenal insufficiency was properly diagnosed or others who are hypotensive, septic, and unresponsive to standard therapy. When glucocorticoids are used, hydrocortisone should be the drug of choice and should be given at the lowest dose and for the shortest duration possible. The hydrocortisone dose (50 mg every 6 h) that is mistakenly labeled as low-dose hydrocortisone leads to excessive elevation in serum cortisol to values severalfold greater than those achieved in patients with documented normal adrenal function. The latter data should call into question the current practice of using such doses of hydrocortisone even in the adrenally insufficient subjects.

Anti-inflammatory therapy in the neonatal intensive care unit: present and future

Inflammation has been linked to numerous adverse outcomes in newborns. This paper reviews several major sources of inflammation, methods to reduce exposure, current anti-inflammatory drug therapy and future research directions. The first major source of inflammation--chorioamnionitis--is often present long before delivery; postnatal interventions may not alter outcomes. Reducing the exposure of preterm infants to postnatal inflammatory stimuli such as mechanical ventilation and sepsis may be more effective than anti-inflammatory drug therapy in improving outcomes. If anti-inflammatory drug therapy is considered necessary, the only drug currently proven to decrease extubation failure and bronchopulmonary dsyplasia (BPD) is dexamethasone, which is associated with numerous side effects. Erythromycin treatment of Ureaplasma urealyticum has been ineffective in reducing BPD; are trials of azythromycin planned. Research may improve future outcomes by tailoring glucocorticoid dosage, duration and formulation in targeted populations and by developing agents to inhibit specific pro-inflammatory mechanisms.

Decreased progression of postinjury lung dysfunction to the acute respiratory distress syndrome and multiple organ failure

BACKGROUND

Postinjury organ dysfunction is a result of unbridled systemic hyperinflammation. According to the two-event construct, patients are resuscitated into an early vulnerable window of systemic hyperinflammation (primed) in which a second otherwise innocuous event precipitates uncontrolled hyperinflammation, leading to secondary organ damage and dysfunction (activated). Recent efforts to decrease postinjury morbidity have focused on limiting the potential of second events and systemic inflammation. We hypothesized that the collective effects of recently implemented therapeutic strategies have resulted in decreased activation of the systemic inflammatory response relative to priming in recent years.

METHODS

Data were collected prospectively on trauma patients at risk for postinjury multiple organ failure (MOF). Inclusion criteria were age >15 years, trauma intensive care unit admission, Injury Severity Score >15 and survival >48 hours. Isolated head injuries and head injuries with an extracranial abbreviated injury score <2 were excluded. Daily physiologic and laboratory data were collected through surgical intensive care unit day 28, and clinical events were recorded thereafter until death or hospital discharge. Organ failure was characterized with the use of the Denver MOF Scale. Acute respiratory distress syndrome (ARDS) was defined according to the consensus definition.

RESULTS

Over a 6.5-year period 897 patients were studied; 271 (31%) developed ARDS, and 226 (25%) developed MOF. Early lung dysfunction, as a measure of systemic priming, did not change over the study period. In contrast, the incidence of ARDS and MOF decreased from 43% to 25% and 33% to 12%, respectively. The incidence of early MOF decreased from 22% to 7% over the study period.

CONCLUSIONS

Priming of the postinjury inflammatory response is an early event and is primarily influenced by the injury itself. Recent advances in postinjury care such as judicious blood transfusion, lung protective ventilation, treatment of adrenal insufficiency, and tight glucose control are known to attenuate systemic inflammation. Step-wise adoption of these therapies is coincident with a decrease in the destructive processes resulting in ARDS and MOF. The global effect is a decrease in activation of the systemic inflammatory response over recent years.

Relative adrenal insufficiency in patients with septic shock; a close look to practice patterns

PURPOSE

To assess patterns of practice in our institution specifically regarding corticosteroid deficiency diagnosis in patients with septic shock.

METHODS

Consecutive adult patients with vasopressor-dependent septic shock admitted to the medical intensive care unit between January 2002 and September 2003 were studied. Relative adrenal insufficiency (RAI) was diagnosed by a random serum cortisol level <or=15 microg/dL or by a random cortisol level between 15 and 34 microg/dL and an increase in response to cosyntropin stimulation test (250 microg) <or=9 microg/dL.

RESULTS

Ninety-two patients were included in the study. Mean (+/-SD) age was 59 +/- 18 years. Overall mortality was 53%. Relative adrenal insufficiency was suspected in 44 (48%) patients and confirmed in 25 (57%). Maximal doses of vasopressors were comparable between groups but more patients in whom AI was suspected were on phenylephrine and/or vasopressin and more were treated with activated protein C (P < .05). Diagnosis of RAI was confirmed by a low basal cortisol (<15 microg/dL) in 12 (48%) patients, whereas a diagnosis of RAI was made by a lack of response to the stimulation test in the rest.

CONCLUSIONS

Relative adrenal insufficiency was diagnosed in half of the patients investigated. Patients with presumed RAI were more likely to be on phenylephrine or vasopressin infusions and treated with activated protein C and had a longer intensive care unit stay but no difference in intensive care unit survival.

Variability of cortisol assays can confound the diagnosis of adrenal insufficiency in the critically ill population

OBJECTIVE

To compare the total plasma cortisol values obtained from three widely used immunoassays and a high pressure liquid chromatography (HPLC) technique on samples obtained from patients with sepsis.

DESIGN AND SETTING

Observational interventional in the general intensive care unit of a metropolitan hospital

PATIENTS AND PARTICIPANTS

Patients admitted to the intensive care unit with a diagnosis of sepsis and fulfilling criteria of systemic inflammatory response syndrome.

INTERVENTIONS

Standard short synacthen test performed with 250microg cosyntropin.

MEASUREMENTS AND RESULTS

Two of the three immunoassays returned results significantly higher than those obtained by HPLC: Immulite by 95% (95%CI 31-188%) and TDx by 79% (21-165%). The limits of agreement for all three immunoassays with HPLC ranged from -62% to 770%. In addition, by classifying the patients into responders and non-responders to ACTH by standard criteria there was concordance in all assays in only 44% of patients.

CONCLUSIONS

Immunoassay estimation of total plasma cortisol in septic patients shows wide assay related variation that may have significant impact in the diagnosis of relative adrenal insufficiency.

Efficacy of hydrocortisone in preventing posttraumatic stress disorder following critical illness and major surgery

Like other humans exposed to extreme trauma, patients who have been treated in an intensive care unit (ICU) often report traumatic memories. Extremely traumatic memories from the ICU in some of these patients are associated with the development of posttraumatic stress disorder (PTSD), which results in significant impairments in health-related quality of life (HRQL) outcomes of ICU therapy. Severely ill patients in the ICU often show insufficient endogenous glucocorticoid signaling, which has recently been termed critical illness-related corticosteroid insufficiency (CIRCI). We performed several controlled trials in ICU patients with suspected CIRCI from septic shock or cardiac surgery, which indicated that the administration of glucocorticoids (stress doses of hydrocortisone) during ICU treatment results in a significant reduction of PTSD symptoms in long-term survivors as well as improvements in HRQL outcomes. Stress doses of hydrocortisone could help to surmount impaired glucocorticoid signaling from CIRCI during critical illness resulting in a downregulation of the stress response as well as inhibition of traumatic memory retrieval and facilitated extinction of aversive information.

Drug Insight: adjunctive therapies in adults with bacterial meningitis

Despite the availability of effective antibiotics, mortality and morbidity rates associated with bacterial meningitis are high. Studies in animals have shown that bacterial lysis, induced by treatment with antibiotics, leads to inflammation in the subarachnoid space, which might contribute to an unfavorable outcome. The management of adults with bacterial meningitis can be complex, and common complications include meningoencephalitis, systemic compromise, stroke and raised intracranial pressure. Various adjunctive therapies have been described to improve outcome in such patients, including anti-inflammatory agents, anticoagulant therapies, and strategies to reduce intracranial pressure. Although a recent randomized trial provided evidence in favor of dexamethasone treatment, few randomized clinical studies are available for other adjunctive therapies in adults with bacterial meningitis. This review briefly summarizes the pathogenesis and pathophysiology of bacterial meningitis, and focuses on the evidence for and against use of the available adjunctive therapies in clinical practice.

Adrenal insufficiency in severe West Nile Virus infection

OBJECTIVE

To explore adrenal function in severe West Nile virus (WNV) infection.

DESIGN AND SETTING

Prospective interventional cohort study in a medical ICU of a teaching hospital.

PATIENTS

Ten consecutive patients (seven men, mean age 64+/-12years, mean SAPS II 26+/-6) with definite diagnosis of WNV related meningoencephalitis and variable proportion of organ/system failure. All patients had fever (mean body temperature 39+/-1 degrees C) and altered mental status (mean Glasgow Coma Score 11+/-2). Mean SOFA score was 9+/-2; eight patients had systemic inflammatory response syndrome, five septic shock, and six acute respiratory failure (usually from central origin) requiring mechanical ventilation.

INTERVENTIONS

A short corticotropin test was performed in each patient to assess the adrenal function.

MEASUREMENTS AND RESULTS

Cortisol response was defined as the difference between baseline and corticotropin-stimulated peak. Absolute adrenal insufficiency was defined by a baseline cortisol level below 15 microg/dl (415 nmol/l). Relative insufficiency was defined by a cortisol response of 9 microg/dl (250 nmol/l) or less. Relative adrenal insufficiency, defined by a corticotropin response below 9 microg/dl, was observed in seven while the remaining three had normal cortisol response; six out of these seven died in the ICU. All patients with normal adrenal function survived.

CONCLUSION

Adrenal insufficiency is frequent in severe WNV infection and carries a poor outcome. In the absence of specific effective treatment, our data provide a rational to investigate a supplemental corticosteroid treatment in a controlled trial.