Corticosteroid insufficiency in acutely ill patients

Neuroendocrine dysfunction in the acute phase of traumatic brain injury

BACKGROUND

Pituitary hormone abnormalities have been reported in up to 50% of survivors of traumatic brain injury (TBI) who were investigated several months or longer following the event. The frequency of pituitary dysfunction in the early post-TBI period is unknown.

AIM

To evaluate the prevalence of anterior and posterior pituitary dysfunction in the early phase following TBI.

SUBJECTS

Fifty consecutive patients admitted to the neurosurgical unit with severe or moderate TBI [initial Glasgow Coma Scale (GCS) score 3-13], and 31 matched healthy control volunteers were studied.

METHODS

The glucagon stimulation test (GST) was performed at a median of 12 days (range 7-20) following TBI. Baseline thyroid function, PRL, IGF-1, gonadotrophins, testosterone or oestradiol, plasma sodium, plasma and urine osmolalities or the standard observed water deprivation test were performed. The control subjects underwent the GST for GH and cortisol responses; other parameters were compared to locally derived reference ranges.

RESULTS

Control data indicated that peak serum GH of > 5 ng/ml and cortisol > 450 nmol/l following glucagon stimulation should be taken as normal. Nine TBI patients (18%) had GH response < 5 ng/ml (12 mU/l). Eight patients (16%) had peak cortisol responses < 450 nmol/l. Compared to controls, basal cortisol values were significantly lower in patients with subnormal cortisol responses to glucagon and significantly higher in patients with normal cortisol responses (P < 0.05). GH and cortisol deficiencies were unrelated to patient age, BMI, initial GCS or IGF-1 values (P > 0.05). Forty patients (80%) had gonadotrophin deficiency, with low sex steroid concentrations, which was unrelated to the presence of hyperprolactinaemia. In males there was a positive correlation between serum testosterone concentration and GCS (r = 0.32, P = 0.04). One patient had TSH deficiency. Hyperprolactinaemia was present in 26 patients (52%) and serum PRL levels correlated negatively with the GCS score (r =-0.36, P = 0.011). Thirteen patients (26%) had cranial diabetes insipidus (DI) and seven (14%) had syndrome of inappropriate ADH secretion.

CONCLUSION

Our data show that post-traumatic neuroendocrine abnormalities occur early and with high frequency, which may have significant implications for recovery and rehabilitation of TBI patients.

Adrenal insufficiency in patients with ruptured abdominal aortic aneurysms

PURPOSE

Failure of the adrenocortical system after open repair of ruptured abdominal aortic aneurysm (RAAA) has never been reported, to our knowledge. This study was undertaken to examine the incidence and response to treatment of adrenal insufficiency in the RAAA population.

METHODS

A 6-year retrospective analysis was carried out on data for all patients admitted after RAAA repair. A cosyntropin stimulation test (CST) was performed in patients with unexplained postoperative hypotension. Patients with adrenal insufficiency were given stress dose hydrocortisone, followed by slow hydrocortisone taper.

RESULTS

Twenty of 26 patients admitted after RAAA repair survived longer than 1 week. Nine of these 20 patients underwent CST because of unexplained hypotension, and six patients were found to have adrenal insufficiency. Compared with the three patients with normal CST and the 11 patients with normotension who did not require testing, patients with adrenal insufficiency had greater preoperative hypotension (83% vs 29%; P =.05), greater operative blood loss (7.0 +/- 1.6 L vs 3.0 +/- 0.9 L; P =.003), longer lower extremity ischemia time (5.0 +/- 2.3 hours vs 1.3 +/- 0.5 hours; P =.025), and lower intraoperative urine output (0.8 +/- 0.4 mL/kg/hr vs 2.1 +/- 0.6 mL/kg/hr; P =.023). No difference in length of stay (40 +/- 18 days vs 35 +/- 26 days), major complications (27% vs 32%), or overall mortality (17% vs 15%) was demonstrated with steroid therapy. Initiation of steroid therapy enabled weaning of vasopressor support within 48 hours in patients with adrenal insufficiency.

CONCLUSIONS

Adrenal insufficiency was identified in 67% of patients with RAAA with unexplained postoperative hypotension given a CST. Predictors of adrenal insufficiency after RAAA repair include preoperative hypotension and a complicated operative course. Steroid therapy can limit vasopressor dependence, and is not associated with increased morbidity or mortality.

Endocrine changes in critical illness

The homeostatic corrections that have emerged in the course of human evolution to cope with catastrophic events involve a complex multisystem endeavor, of which the endocrine contribution is an integral component. Although the repertoire of endocrine changes has been probed in some detail, discerning the vulnerabilities and failure of this system is far more challenging. The ensuing endocrine topics illustrate some of the current issues reflecting attempts to gain an improved insight and clinical outcome for critical illness.

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

We used a modified Delphi methodology for grading recommendations, built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.

RESULTS

Key recommendations, listed by category and not by hierarchy, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition; appropriate diagnostic studies to ascertain causative organisms before starting antibiotics; early administration of broad-spectrum antibiotic therapy; reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate; a usual 7-10 days of antibiotic therapy guided by clinical response; source control with attention to the method that balances risks and benefits; equivalence of crystalloid and colloid resuscitation; aggressive fluid challenge to restore mean circulating filling pressure; vasopressor preference for norepinephrine and dopamine; cautious use of vasopressin pending further studies; avoiding low-dose dopamine administration for renal protection; consideration of dobutamine inotropic therapy in some clinical situations; avoidance of supranormal oxygen delivery as a goal of therapy; stress-dose steroid therapy for septic shock; use of recombinant activated protein C in patients with severe sepsis and high risk for death; with resolution of tissue hypoperfusion and in the absence of coronary artery disease or acute hemorrhage, targeting a hemoglobin of 7-9 g/dL; appropriate use of fresh frozen plasma and platelets; a low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome; application of a minimal amount of positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome; a semirecumbent bed position unless contraindicated; protocols for weaning and sedation/analgesia, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening; avoidance of neuromuscular blockers, if at all possible; maintenance of blood glucose <150 mg/dL after initial stabilization; equivalence of continuous veno-veno hemofiltration and intermittent hemodialysis; lack of utility of bicarbonate use for pH > or =7.15; use of deep vein thrombosis/stress ulcer prophylaxis; and consideration of limitation of support where appropriate. Pediatric considerations included a more likely need for intubation due to low functional residual capacity; more difficult intravenous access; fluid resuscitation based on weight with 40-60 mL/kg or higher needed; decreased cardiac output and increased systemic vascular resistance as the most common hemodynamic profile; greater use of physical examination therapeutic end points; unsettled issue of high-dose steroids for therapy of septic shock; and greater risk of hypoglycemia with aggressive glucose control.

CONCLUSION

Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that are hoped to translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually and even more rapidly as some important new knowledge becomes as available.

The low-dose corticotropin stimulation test in acute traumatic and non-traumatic brain injury: incidence of hypo-responsiveness and relationship to outcome

OBJECTIVE

To investigate adrenal responses to the low-dose corticotropin (ACTH) stimulation test in acute traumatic or non-traumatic brain injury (BI) and to assess its value in predicting outcome.

DESIGN

Prospective study. SETTING. Intensive care unit (ICU) in a university hospital.

PATIENTS AND PARTICIPANTS

Seventy-five patients with acute BI, with a median age of 45 years were investigated. BI was due to trauma ( n=51), ischemic stroke ( n=17), subarachnoid hemorrhage ( n=4) or intracerebral hemorrhage (n=3).

INTERVENTIONS

Blood was taken on day 16 (median) after admission to the ICU to determine baseline cortisol and ACTH. Thereafter, a low-dose stimulation test (LDST) was performed: 1 microg of tetracosactrin was injected and 30 min later a second blood specimen was obtained to measure stimulated cortisol. Patients having a stimulated cortisol below 500 nmol/l were defined as non-responders to the LDST.

MEASUREMENTS AND RESULTS

Median baseline and stimulated cortisol were 491 nmol/l and 690 nmol/l, respectively. The median increment in cortisol was 154 nmol/l (range 5-579 nmol/l). Mean ACTH was 46+/-21 pg/ml. Ten (13%) patients were non-responders to the LDST; these had a higher mortality rate compared to patients with adequate cortisol production (70 vs 32%, p=0.034). Logistic regression analysis revealed that APACHE II ( p<0.001), Glasgow Coma Scale (GCS) ( p=0.04) and age ( p=0.02) were independent outcome predictors. In contrast, the increment in cortisol ( p=0.26) did not add to outcome prediction.

CONCLUSIONS

Adrenal hypo-responsiveness in the setting of acute traumatic or non-traumatic BI is not an independent outcome predictor in the presence of high APACHE II, low GCS and older age.

Measurements of serum free cortisol in critically ill patients

BACKGROUND

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

OBJECTIVE

To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A-E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.

PARTICIPANTS

Participants included 44 critical care and infectious disease experts representing 11 international organizations.

RESULTS

A total of 46 recommendations plus pediatric management considerations.

CONCLUSIONS

Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.

Steroids in adults with acute bacterial meningitis: a systematic review

Bacterial meningitis is uncommon but causes significant mortality and morbidity, despite optimum antibiotic therapy. A clinical trial in 301 patients showed a beneficial effect of adjunctive steroid treatment in adults with acute community-acquired pneumococcal meningitis, but data on other organisms or adverse events are sparse. This led us to do a quantitative systematic review of adjunctive steroid therapy in adults with acute bacterial meningitis. Five trials involving 623 patients were included (pneumococcal meningitis=234, meningococcal meningitis=232, others=127, unknown=30). Overall, treatment with steroids was associated with a significant reduction in mortality (relative risk 0.6, 95% CI 0.4-0.8, p=0.002) and in neurological sequelae (0.6, 0.4-1, p=0.05), and with a reduction of case-fatality in pneumococcal meningitis of 21% (0.5, 0.3-0.8, p=0.001). In meningococcal meningitis, mortality (0.9, 0.3-2.1) and neurological sequelae (0.5, 0.1-1.7) were both reduced, but not significantly. Adverse events, recorded in 391 cases, were equally divided between the treatment and placebo groups (1, 0.5-2), with gastrointestinal bleeding in 1% of steroid-treated and 4% of other patients. Since treatment with steroids reduces both mortality and neurological sequelae in adults with bacterial meningitis, without detectable adverse effects, routine steroid therapy with the first dose of antibiotics is justified in most adult patients in whom acute community-acquired bacterial meningitis is suspected.

Stress doses of hydrocortisone, traumatic memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study

BACKGROUND

Traumatic experiences associated with cardiac surgery (CS) can result in traumatic memories and posttraumatic stress disorder (PTSD). Because it is known that subjects who develop PTSD often show sustained reductions in circulating cortisol concentrations, we performed a prospective, randomized study to examine whether exogenously administered stress doses of hydrocortisone during the perioperative period of CS reduces the long-term incidence of chronic stress and PTSD symptoms.

METHODS

Patients (n = 91) were prospectively randomized to receive either stress doses of hydrocortisone or standard treatment during the perioperative period of CS. Of 48 available patients at 6 months after CS, 26 had received stress doses of hydrocortisone and 22 standard treatment. Traumatic memories and PTSD symptoms were diagnosed with previously validated questionnaires.

RESULTS

As compared with patients after standard therapy, patients from the hydrocortisone group had significantly lower chronic stress symptom scores (p <.05). There was no significant difference regarding the number or type of traumatic memories between the hydrocortisone and the standard treatment groups.

CONCLUSIONS

Stress doses of hydrocortisone in patients undergoing CS are associated with a lower intensity of chronic stress and PTSD symptoms at 6 months after CS.

Adrenocortical function and dysfunction in the fetus and neonate

Under normal circumstances, the fetus is exposed to very low concentrations of cortisol until late in gestation. Perturbations of the intra-uterine environment resulting in fetal exposure to increased cortisol may have consequences not only in infancy, but also into adult life. In the postnatal period, developmental immaturity and/or the effects of critical illness on adrenal function may result in insufficient cortisol production to maintain homeostasis in the face of acute stress or illness, a situation that has been labelled 'relative adrenal insufficiency' in other acutely ill populations. The definition of inadequate adrenal function in the newborn and its possible relationship to adverse outcomes in both premature and term infants are only beginning to be characterized.

Pharmacologic treatment of acute renal failure in sepsis

The pathophysiology of acute renal failure in sepsis is complex and includes intrarenal vasoconstriction, infiltration of inflammatory cells in the renal parenchyma, intraglomerular thrombosis, and obstruction of tubuli with necrotic cells and debris. Attempts to interfere pharmacologically with these dysfunctional pathways, including inhibition of inflammatory mediators, improvement of renal hemodynamics by amplifying vasodilator mechanisms and blocking vasoconstrictor mechanisms, and administration of growth factors to accelerate renal recovery, have yielded disappointing results in clinical trials. Interruption of leukocyte recruitment is a potential promising approach in the treatment of septic acute renal failure, but no data in humans are presently available. Activated protein C and steroid replacement therapy have been shown to reduce mortality in patients with sepsis and are now accepted adjunctive treatment options for sepsis in general.

Role of Corticosteroids in Septic Shock

OBJECTIVE

To highlight the role of relative adrenal insufficiency in the outcome of critically ill patients with sepsis and systematically review the literature regarding the use of corticosteroids for management of severe sepsis/septic shock.

DATA SOURCES

A computerized search of MEDLINE, EMBASE, and the Cochrane Database was undertaken from 1966 to March 2003 using the search terms intensive care unit, critical care, corticosteroids, glucocorticoids, adrenal insufficiency, sepsis, and septic shock. Bibliographies of all articles retrieved were searched for relevant articles not identified by the computerized search.

DATA EXTRACTION/SYNTHESIS

Six trials were identified after publication of the meta-analyses (1995), with a total of 505 patients. The results of these trials in septic shock suggest that low-dose corticosteroids can reduce vasopressor requirements and hasten reversal of shock. Some of these trials suggested a possible mortality benefit from therapy, and no trial demonstrated an increase in mortality or significant adverse effects. The benefit of this therapy may depend on the presence of relative adrenal insufficiency, as identified by the adrenocorticotropic hormone stimulation test.

CONCLUSIONS

Low-dose corticosteroids should be administered to patients with septic shock empirically, but should be discontinued if relative adrenal insufficiency is not confirmed.

Corticosteroids for treating severe sepsis and septic shock

BACKGROUND

Sepsis may be complicated by impaired corticosteroid production. Giving corticosteroids could potentially benefit patients.

OBJECTIVES

To examine the effects of corticosteroids on death at one month in patients with severe sepsis and septic shock.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group's trial register (August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003), MEDLINE (August 2003), EMBASE (August 2003), LILACS (August 2003), reference lists of articles, and also contacted trial authors.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials of corticosteroids versus placebo or supportive treatment in severe sepsis and septic shock.

DATA COLLECTION AND ANALYSIS

Two pairs of reviewers agreed the eligibility of trials. One reviewer extracted data, which was checked by the other reviewers and the primary author of the paper whenever possible. We obtained some missing data from the trial authors. We assessed trial methodological quality.

MAIN RESULTS

We identified 15 trials (n =2023). Corticosteroids did not change 28-day all-cause mortality (15 trials, n = 2022, relative risk (RR) 0.92, 95% confidence interval (CI) 0.75 to 1.14; random effects model) and hospital mortality (13 trials, n = 1418, RR 0.89, 95% CI 0.71 to 1.11; random effects model); however, there was statistically significant heterogeneity, with some evidence that this was related to the dosing strategy. Corticosteroids reduced intensive care unit mortality (4 trials, n = 425, RR 0.83, 95% CI 0.70 to 0.97), increased the proportion of shock reversal by day 7 (6 trials, n = 728, RR 1.22, 95% CI 1.06 to 1.40) and by day 28 (4 trials, n = 425, RR 1.26, 95% CI 1.04 to 1.52), without increasing the rate of gastroduodenal bleeding (10 trials, n = 1321, RR 1.16, 95% CI 0.82 to 1.65), superinfection (12 trials, n = 1705, RR 0.93, 95% CI 0.73 to 1.18), and of hyperglycaemia (6 trials, n = 608, RR 1.22, 0.84 to 1.78).

REVIEWER'S CONCLUSIONS

Overall, corticosteroids did not change 28-day mortality and hospital mortality in severe sepsis and septic shock. Long course of low dose corticosteroids reduced 28-day all-cause mortality, and intensive care unit and hospital mortality.

Cortisol levels and mortality in severe sepsis

OBJECTIVE

Serum cortisol levels rise in response to the stress of critical illness but the optimal range of serum cortisol in such settings is not clearly defined. The objectives of this study were to determine the range of serum cortisol levels in a group of medical intensive care unit patients with severe sepsis/septic shock using uniform criteria, and to correlate serum cortisol levels to mortality.

DESIGN AND PATIENTS

In a prospective observational fashion, 100 medical intensive care unit patients at Northwestern Memorial Hospital in Chicago were enrolled within 48 h of developing severe sepsis/septic shock as defined by the American College of Chest Physicians/Society of Critical Care Medicine.

MEASUREMENTS

A serum cortisol level was measured during the morning hours in the first 48 h of developing severe sepsis/septic shock. The severity of critical illness was measured by the Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

RESULTS

The average patient age was 63 +/- 17 years, 54 patients were men. The average APACHE II score for all patients was 23 +/- 7. In-hospital and 90-day mortality were 51% and 60%, respectively. Four patient groups were defined a priori based on morning serum cortisol levels and their in-hospital mortalities were as follows: group 1 (cortisol < or = 345 nmol/l), n = 11, mortality 54%; group 2 (cortisol 345-552 nmol/l), n = 19, mortality 53%; group 3 (cortisol 552-1242 nmol/l), n = 54, mortality 41%; and group 4 (cortisol > or = 1242 nmol/l), n = 16, mortality 81% (P < 0.01).

CONCLUSIONS

Cortisol levels were elevated in most patients with septic shock. Cortisol levels less than 552 nmol/l occurred in 30% of patients with septic shock but the mortality in these patients was not significantly increased. Serum cortisol levels > or = 1242 nmol/l were associated with significantly higher mortality.

Acute chagas' disease presenting with a suprasellar mass and panhypopituitarism

Although intrinsic pituitary lesions are the most common cause of hypopituitarism, suprasellar masses can produce similar symptoms. The differential diagnosis of a suprasellar mass includes cystic lesions, tumors, granulomatous disease, and infection. The etiology is not always obvious, and despite extensive work-up, may remain elusive. A 28-year-old Mexican man presented with complaints of headache and weakness for two weeks duration. He became increasingly lethargic and an MRI revealed a two centimeter suprasellar mass. Testing of the hypothalamic-pituitary axis suggested panhypopituitarism. He was prescribed treatment with hydrocortisone, DDAVP, and levothyroxine. Open craniotomy and biopsy of the hypothalamus revealed marked inflammation with plasma cells, histiocytes, and small lymphocytes. Light microscopy revealed macrophage-contained leishmania-like organisms although results were not immediately available. Pathological data was consistent with acute infection by Trypanasoma cruzi. Despite supportive efforts, the patient expired two months after presentation. This case illustrates the difficulty of diagnosing and the potential rapid mortality of a suprasellar mass. Because of the wide consideration of etiologies, a tissue diagnosis is needed. However, as this case illustrates, a definitive tissue diagnosis is not always possible, even following biopsy during open craniotomy.

High altitude sickness. Is acute cortisol deficiency involved in its pathophysiology?

High altitude illness (HAI) affects 42% of individuals climbing above 3000 m. The pathophysiology of HAI, including water retention remains unclear. Although decreased nitric oxide (NO) production is implicated in the pathophysiology, a recent study reported increased NO in breathes of high altitude inhabitants, apparently produced to combat the high altitude hypoxia. NO binds heme generally and impairs cytochrome P450 steroidogenic enzymes. A consequence of increased NO production may be decreased steroidogenesis. An acute cortisol deficiency may thus be the reason for water retention and oedema, and explains why dexamethasone is effective in treating some aspects of HAI.

Critical issues in endocrinology

Endocrine emergencies are commonly encountered in the ICU. This article focuses on several important endocrine emergencies, including diabetic hyperglycemic states, adrenal insufficiency, myxedema coma, thyroid storm, and pituitary apoplexy. Other endocrine issues that are related to intensive care, such as intensive insulin therapy, relative adrenal insufficiency, and thyroid function test abnormalities are also covered in detail.

[A puzzling circulatory failure after total hip replacement]

The diagnosis of acute circulatory failure in the postoperative course of hip replacement must concentrate on frequent complications, but rare complications requiring specific treatment must also be diagnosed. We report on the occurrence of a case of acute adrenal insufficiency subsequent to enoxaparin-induced type II thrombocytopenia. A delay was necessary to establish a correct diagnosis for two reasons: (1) an unusual clinical presentation and (2) an underevaluation of the medical risk during the preoperative visit. The evolution was nevertheless favorable after prescription of steroids that had to be prescribed chronically.

Management of Severe Sepsis: Integration of Multiple Pharmacologic Interventions

Severe sepsis is an infection-induced process that often promotes organ dysfunction and death in up to 50% of afflicted patients. Clinical advances that improve patient survival include early goal-directed volume resuscitation, broad-spectrum empiric antimicrobial therapy with deescalation strategies, therapy with drotrecogin alfa (activated), glucocorticoid replacement in patients with adrenal insufficiency, and tight control of blood glucose levels. The challenge for critical care practitioners is to integrate the many pharmacologic and supportive interventions required for optimal care of these patients.

New treatment strategies for severe sepsis and septic shock

PURPOSE OF REVIEW

Severe sepsis and septic shock are common causes of morbidity and mortality in critically ill patients. The complexities of the septic cascade continue to emerge and may identify new targets for innovative patient management. This review will highlight some of the recent advances in our management of the patient with sepsis.

RECENT FINDINGS

The early administration of adequate antibiotic therapy, effective source control, and goal-directed hemodynamic resuscitation are the cornerstone of successful management. Prevention of the complications of critical illness and maintenance of normal glucose levels are also important elements of effective management. In patients with vasopressor-dependent septic shock, evaluation for inadequate cortisol response and the provision of physiologic doses of replacement steroids for those found to be deficient 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. Because of its anticoagulant properties, caution must be exercised with the use of activated protein C in those patients who meet the contraindications for its use or who have risk factors for increased bleeding complications.

SUMMARY

Significant advances have been made in our understanding of the septic cascade and our ability to manage patients with severe sepsis and septic shock. Despite these advances, significant morbidity and mortality continue. In addition, there is also considerable impact on the financial and overall function of the patient.

Clinical review: corticotherapy in sepsis

The use of glucocorticoids (corticotherapy) in severe sepsis is one of the main controversial issues in critical care medicine. These agents were commonly used to treat sepsis until the end of the 1980s, when several randomized trials casted serious doubt on any benefit from high-dose glucocorticoids. Later, important progress in our understanding of the role played by the hypothalamic–pituitary–adrenal axis in the response to sepsis, and of the mechanisms of action of glucocorticoids led us to reconsider their use in septic shock. The present review summarizes the basics of the physiological response of the hypothalamic–pituitary–adrenal axis to stress, including regulation of glucocorticoid synthesis, the cellular mechanisms of action of glucocorticoids, and how they influence metabolism, cardiovascular homeostasis and the immune system. The concepts of adrenal insufficiency and peripheral glucocorticoid resistance are developed, and the main experimental and clinical data that support the use of low-dose glucocorticoids in septic shock are discussed. Finally, we propose a decision tree for diagnosis of adrenal insufficiency and institution of cortisol replacement therapy.

Modulation of host defense by hydrocortisone in stress doses during endotoxemia

OBJECTIVE

To investigate the effects of low-dose hydrocortisone (HC) on neutrophil respiratory burst, phagocytosis, and elimination of E. coli from blood and tissue under endotoxemic and non-endotoxemic conditions. DESIGN. Randomized, controlled trial.

SETTING

Experimental laboratory, university hospital.

SUBJECTS

Forty-eight female chinchilla rabbits ( n=8 in six groups A-F).

INTERVENTIONS

In order to quantify the bacterial clearance process, defined numbers [10(8) colony forming units (CFU)] of Escherichia coli were injected intravenously into all anesthetized rabbits. Group A did not receive further intervention. Group B received bolus administration of HC 1.4 mg/kg and group C 14 mg/kg. Endotoxin (LPS, 40 microg/kg/h) was given to groups D, E, and F. Group E received additional bolus administration of HC 1.4 mg/kg and group F 14 mg/kg. All HC groups (B, C, E, and F) were continuously infused with HC 0.18 mg/kg/h.

MEASUREMENTS

Monitored parameters were neutrophil respiratory burst and phagocytosis activity, rates of bacterial elimination from the blood, arterial blood pressure, serum lactate and LPS concentrations, as well as nitrite and nitrate levels. Tissue samples of liver, kidney, spleen, and lung were collected for bacterial counts.

MAIN RESULTS

In controls HC significantly delayed elimination of injected E. coli from the blood (P<0.01). LPS also prolonged bacterial elimination but additional HC did not further delay removal of E. coli from the blood. Under endotoxemia HC depressed respiratory burst, whereas phagocytosis functions remained unaltered. Moreover, bacterial colonization of organs was reduced after HC in the LPS groups. Significance, however, was reached only in the liver (P<0.05). Due to HC, clearance from LPS (P<0.01) and lactate (P<0.05) were improved. Levels of nitrite and nitrate did not differ among the groups.

CONCLUSION

HC demonstrated immunomodulatory effects even in stress doses. In endotoxemic states use of low-dose HC seems to be favorable, although not in non-septic conditions.

Glucocorticoid insufficiency in patients who present to the hospital with severe sepsis: a prospective clinical trial

OBJECTIVE

To identify the incidence of secondary adrenal insufficiency in severe sepsis.

DESIGN

Prospective clinical trial testing 100 patients with a 250-microg adrenocorticotropic hormone (ACTH) stimulation test.

SETTING

County-university teaching hospital.

PATIENTS

One hundred patients with sepsis and septic shock. Forty patients had bacteremia and 17% shock.

INTERVENTIONS

ACTH, cortisol, aldosterone, and electrolyte concentrations were measured at baseline. Cortisol and aldosterone were measured 30 and 60 mins after ACTH (250 microg).

MEASUREMENTS AND MAIN RESULTS

Nine of the 100 patients (9%) failed the ACTH stimulation test (all serum cortisol <20 microg/dL). The 91 patients with sepsis began with a serum cortisol at 29.3 +/- 2.5, and it increased to 40.1 +/- 2.6 and 46.9 +/- 2.7 microg/dL at times 30 and 60 mins, respectively. Serum cortisol in nine septic patients who failed the ACTH stimulation test had an initial concentration of 11.3 +/- 1.8 microg/dL, and it increased at time 30 mins to 14.0 +/- 1.9 microg/dL and at 60 mins to 15.7 +/- 1.8 microg/dL. Four of the nine patients had secondary adrenal insufficiency as determined by a normal aldosterone response to ACTH. The remaining five patients had an absent aldosterone response to ACTH and baseline ACTH concentrations that were not elevated, suggesting adrenal dysfunction. Serum sodium (128 +/- 4 vs. 138 +/- 1 mmol/L, p <.05) and glucose concentrations (121 +/- 20 vs. 163 +/- 11 mg/dL, p <.05) were reduced in the nine patients. Of the four patients with secondary adrenal insufficiency, two had a history of amenorrhea after birth of their children many years earlier.

CONCLUSIONS

These data demonstrate that 9% of adults with sepsis fail the ACTH stimulation test due to a mixture of etiologies. A reduced sodium or glucose concentration may be helpful in identifying glucocorticoid (adrenal) insufficiency in patients with sepsis.

Tratamiento del shock séptico con plasmafiltración y hemodiafiltración continuas simultáneas

Despite recent therapeutic advances, mortality due to septic shock remains high. The most important causes of mortality are refractory shock, uncontrollable alterations of coagulation, and multiorgan failure. Some authors have proposed the early use of plasmafiltration and high flow hemodiafiltration for refractory septic shock. Most authors initiate treatment with a short session of plasmafiltration followed by continuous hemodiafiltration. A 13-year-old girl presented refractory meningococcal septic shock, disseminated intravascular coagulation, and acute renal failure unresponsive to volume expansion and high doses of adrenalin and noradrenaline. She received simultaneous treatment with plasmafiltration and continuous venovenous hemodiafiltration for 30 hours. Two pumps of extrarenal purification placed in parallel through the same double line catheter were used. Fast hemodynamic stabilization and control of the coagulopathy were achieved. The patient survived with progressive recovery of renal function but required amputation of the inferior left limb. Continuous plasmafiltration and venovenous hemodiafiltration can be used simultaneously for the treatment of older children with septic shock, severe coagulopathy, and hypervolemia.