Download PDF
Horm Metab Res 2012; 44(04): 296-301
DOI: 10.1055/s-0032-1304320
Humans, Clinical
© Georg Thieme Verlag KG Stuttgart · New York

Comparison of Low and High Dose Cosyntropin Stimulation Tests in the Diagnosis of Adrenal Insufficiency in Septic Shock Patients

R. B. Moraes
1   Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
,
G. Friedman
1   Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
,
T. Tonietto
1   Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
,
H. Saltz
1   Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
,
M. Czepielewski
2   Division of Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
› Author Affiliations
Further Information

Publication History

received 01 June 2011

accepted aftersecond revision  19 January 2012

Publication Date:
20 February 2012 (online)

Also available at
    Permissions and Reprints

Abstract

Stress situations such as septic shock are accompanied by activation of the HPA axis. Some patients do not activate this axis in stress situations. This blunted response is currently designated as critical illness-related corticosteroid insufficiency (CIRCI). Currently the 250 μg cosyntropin stimulation test is the preferred diagnostic test for CIRCI. Few papers explored the role of the 1 μg cosyntropin test in septic shock patients. In this study, we compared both tests in septic shock patients taking a special interest in the population with intermediary baseline cortisol. Prospective noninterventional study included 74 septic shock patients. After measurement of baseline cortisol all patients received 1 μg of cosyntropin i. v. and 4 h later 249 μg of cosyntropin. We compared the cortisol increase after each test and its relation to mortality and vasopressor therapy. There was a moderate correlation in response to low and high dose cosyntropin, rs=0.55. This correlation in patients with baseline cortisol between 10–34 μg/dl is, rs=0.67. The increase induced by both tests was equally accurate to identify mortality and time of vasopressor withdrawal. Low and high dose cosyntropin tests presented a moderate correlation in patients with baseline cortisol between 10–34 μg/dl. Both tests are equally accurate to identify mortality and time of vasopressor therapy. These results suggest that both tests could be used to diagnose CIRCI.

Key words

adrenal insufficiency - septic shock - cosyntropin
 

  • References

  • 1 Prigent H, Maxime V, Annane D. Science review: mechanisms of impaired adrenal function in sepsis and molecular actions of glucocorticoids. Crit Care 2004; 8: 243-252
    CrossrefPubMedGoogle Scholar
  • 2 Rothwell PM, Udwadia ZF, Lawler PG. Cortisol response to corticotropin and survival in septic shock. Lancet 1991; 337: 582-583
    CrossrefPubMedGoogle Scholar
  • 3 Marik PE. The adrenal exhaustion syndrome in patients with liver disease. Intensive Care Med 2006; 32: 275-280
    CrossrefPubMedGoogle Scholar
  • 4 Annane D, Sébille V, Troché G, Raphael JC, Gajdos P, Bellissant E. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000; 283: 1038-1045
    CrossrefPubMedGoogle Scholar
  • 5 de Jong MFC, Beishuizen A, Spijkstra JJ, Groeneveld AB. Relative adrenal insufficiency as a predictor of disease severity, mortality, and beneficial effects of corticosteroid treatment in septic shock. Crit Care Med 2007; 35: 1896-1903
    CrossrefPubMedGoogle Scholar
  • 6 Annane D, Sebille V, Charpentier C, Bollaert PE, François B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troché G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-871
    CrossrefPubMedGoogle Scholar
  • 7 Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J. CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008; 358: 111-124
    CrossrefPubMedGoogle Scholar
  • 8 Marik PE. Critical Illness-Related Corticosteroid Insufficiency. CHEST 2009; 135: 181-193
    CrossrefPubMedGoogle Scholar
  • 9 Arafah BM. Hypothalamic Pituitary Adrenal Function during Critical Illness: Limitations of Current Assessment Methods. J Clin Endocrinol Metab 2006; 91: 3725-3745
    CrossrefPubMedGoogle Scholar
  • 10 Annane D, Maxime V, Ibrahim F, Alvares JC, Abe E, Boudou P. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006; 174: 1319-1326
    CrossrefPubMedGoogle Scholar
  • 11 Máxime V, Lesur O, Annane D. Adrenal Insufficiency in Septic Shock. Clin Chest Med 2009; 30: 17-27
    CrossrefPubMedGoogle Scholar
  • 12 Zaloga GP, Marik P. Hypothalamic pituitary insufficiency. Crit Care Clin 2001; 17: 25-41
    CrossrefPubMedGoogle Scholar
  • 13 Cooper MS, Stewart PM. Corticosteroid Insufficiency in Acutely Ill Patients. N Engl J Med 2003; 348: 727-734
    CrossrefPubMedGoogle Scholar
  • 14 Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med 2004; 350: 1629-1638
    CrossrefPubMedGoogle Scholar
  • 15 Arafah BM, Nishiyama FJ, Tlaygeh H, Hejal R. Measurement of Salivary Cortisol Concentration in the Assessment of Adrenal Function in Critically Ill Subjects: A Surrogate Marker of the Circulating Free Cortisol. J Clin Endocrinol Metab 2007; 92: 2965-2971
    CrossrefPubMedGoogle Scholar
  • 16 Kazlauskaite R, Evans AT, Villabona CV, Abdu TA, Ambrosi B, Atkinson AB, Choi CH, Clayton RN, Courtney CH, Gonc EN, Maghnie M, Rose SR, Soule SG, Tordjman K. Consortium for Evaluation of Corticotropin Test in Hypothalamic-Pituitary Adrenal Insufficiency. Corticotropin tests for hypothalamic-pituitary-adrenal insufficiency: a metaanalysis. J Clin Endocrinol Metab 2008; 93: 4245-4253
    CrossrefPubMedGoogle Scholar
  • 17 Marik PE, Zaloga GP. Adrenal insufficiency during septic shock. Critical Care Medicine 2003; 31: 141-145
    CrossrefPubMedGoogle Scholar
  • 18 Salgado DR, Verdeal JCR, Rocco JR. Adrenal function testing in patients with septic shock. Critical Care 2006; 10: R149
    CrossrefPubMedGoogle Scholar
  • 19 Siraux V, De Backer D, Yalavatti G, Mélot C, Gervy C, Mockel J, Vincent JL. Relative adrenal insufficiency in patients with septic shock: Comparison of low-dose and conventional corticotropin tests. Crit Care Med 2005; 33: 2479-2486
    CrossrefPubMedGoogle Scholar
  • 20 Marik PE, Pastores SM, Annane D, Meduri GU, Sprung CL, Arlt W, Keh D, Briegel J, Beishuizen A, Dimopoulou I, Tsagarakis S, Singer M, Chrousos GP, Zaloga G, Bokhari F, Vogeser M. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Crit Care Med. Crit Care Med 2008; 36: 1937-1949
    CrossrefPubMedGoogle Scholar
  • 21 Moraes RB, Czepielewski MA, Friedman G. Is the cosyntropin test necessary in high basal corticoid patients with septic shock?. Crit Care Med 2009; 37: 385-386
    PubMedGoogle Scholar
  • 22 ACCP/SCCM Consensus Conference . Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20: 864-874
    CrossrefPubMedGoogle Scholar
  • 23 Schroeder S, Wichers M, Klingmüller D, Höfer M, Lehmann LE, von Spiegel T, Hering R, Putensen C, Hoeft A, Stüber F. The hypothalamic-pituitary-adrenal axis of patients with severe sepsis: Altered response to corticotropin-releasing hormone. Crit Care Med 2001; 29: 310-316
    CrossrefPubMedGoogle Scholar
  • 24 Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985. 13. 818-829
    Google Scholar
  • 25 Ludbrook J, Royse AG. Analyzing clinical studies: principles and pitfalls of Kaplan-Meier plots. ANZ J Surg 2008; 78: 204-210
    CrossrefPubMedGoogle Scholar
  • 26 Putter H, Fiocco M, Geskus RB. Tutorial in biostatistics: Competing risks and multi-state models. Statist Med 2007; 26: 2389-2430
    CrossrefPubMedGoogle Scholar
  • 27 Teles JM, Silva E, Westphal G, Filho RC, Machado FR. Surviving Sepsis Campaign in Brazil. Shock 2008; 30: 47-52
    CrossrefPubMedGoogle Scholar