CHEST

CHEST

Volume 119, Issue 3, March 2001, Pages 889-896
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Clinical Investigations in Critical Care
Adrenal Insufficiency in High-Risk Surgical ICU Patients

https://doi.org/10.1378/chest.119.3.889Get rights and content

Study objectives:

To examine the incidence and responseto treatment of adrenal insufficiency (AI) in high-risk postoperativepatients.

Design:

Prospective observational caseseries.

Settings:

Large urban tertiary-care surgicalICU (SICU).

Participants:

Adults > 55 years of agewho required vasopressor therapy after adequate volume resuscitation in the immediate postoperative period.

Interventions:

Each patient underwent a cosyntropin (ACTH) stimulation test; at thediscretion of the clinical team, some patients were empirically givenhydrocortisone (100 mg IV q8h for three doses) before serum cortisolvalues became available.

Measurements:

Adrenaldysfunction (AD), defined as serum cortisol < 20μg/dL at all timepoints, with Δcortisol (60 min post-ACTH minus baseline) of ≤ 9μg/dL; functional hypoadrenalism (FH), defined as serum cortisol< 30μg/dL at all time points or Δcortisol (60 min post-ACTHminus baseline) ≤ 9μg/dL; and AI, as the presence of either AD or FH.

Results:

One hundred four patients were enrolledwith a mean age (SD) of 65.2 ± 16.9 years. AI (AD plus FH) was foundin 34 of 104 patients (32.7%): AD was found in 9 patients (8.7%), FHin 25 patients (24%), and normal adrenal function in 70 patients(67.3%). The absolute eosinophil count was significantly higher in thecombined AD and FH groups compared with the group with normal adrenalfunction (p < 0.05). Forty-six of 104 patients (44.2%) receivedhydrocortisone; 29 (63%) could be weaned from treatment with vasopressors with in 24 h. This beneficial effect of hydrocortisonereached statistical significance in the FH group when compared with untreated patients (p < 0.031); a similar trend was seen in the ADgroup (p = 0.083). Mortality was also lower in thehydrocortisone-treated AI patients (5 of 23 [21%] vs 5 of 11[45%] in those not receiving hydrocortisone; p < 0.01).

Conclusion:

There is a high incidence of AI amongSICU patients > 55 years of age with postoperative hypotensionrequiring vasopressors. There is also a significant association betweenhydrocortisone replacement therapy, resolution of vasopressorrequirements, and improved survival.

Section snippets

Study Design

This study was approved by the Henry Ford Health SystemsInstitutional Review Board for Human Research. This was a prospective, nonoutcome, observational convenience case study of adult patients in alarge, urban, tertiary-care SICU during a 2-year period (from 1995 to1997).

Patient Selection

Consecutive postoperative patients > 55 years of age whoexperienced hypotension requiring vasopressor therapy after adequatevolume resuscitation with in 24 h of SICU admission were enrolledin this study. All patients initially

Results

A total of 104 patients were enrolled in the study; themean age was 65.2 ± 16.9 years, and surgical diagnoses are listed inTable 1. Adrenal function was abnormal in 34 of 104 of all patients (32.7%); 9patients (8.7%) had AD and 25 (24%) had FH (Table 2). All patients enrolled fulfilled criteria for the systemicinflammatory response syndrome and were classified as having severesepsis or septic shock.20 Seventy patients (67.3%)exhibited normal baseline serum cortisol (> 20μg/dL) and responseto

Discussion

Cortisol is a major stress response hormone that has metabolic, catabolic, anti-inflammatory, and vasoactive properties on cardiacmuscle and the peripheral vasculature. Thus, cortisol mediatesmaintenance of peripheral vasomotor tone by facilitatingcatecholamine-induced vasoconstriction and has a permissive effect onthe synthesis of catecholamines and vasoactivepeptides.2122 Cortisol also has inotropic effects and modulates free water distribution with in the vascularcompartment.5 In response to

Conclusion

Although the incidence of AI is higher than normal in criticallyill patients, the incidence in surgical ICU patients is even higherwhen restricting the evaluation to patients with the risk factors of age > 55 years and postoperative hypotension requiring vasopressorsafter adequate volume resuscitation. In that setting, the laboratoryexamination and hemodynamic profile do not assist in the diagnosis of AI, except for the presence of eosinophilia. Administration of hydrocortisone replacement

ACKNOWLEDGMENT

The authors thank Julie Massura, MS, and Gary Chase, PhD, for their biostatistical expertise and AlexandriaMuzzin and Julie Ressler for their contributions to the article.

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    Copyright © 2001 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.